Prognostic Implications of Left Ventricular Ejection Fraction Across the Flow‐Gradient Patterns in Severe Aortic Stenosis

Background Current guidelines classify normal‐flow low‐gradient (LG) aortic stenosis (AS) with left ventricular ejection fraction (LVEF) ≥50% as “moderate.” However, the prognostic impact of LVEF remains incompletely understood across various hemodynamic subtypes of AS. Methods We analyzed 3363 consecutive patients with severe AS from the CURRENT AS Registry‐2 (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis). Patients were classified into LG AS with normal flow (N=1005), and LG AS with low flow (N=372), and high‐gradient AS (N=1986). Patients were further divided according to baseline LVEF: <50%, 50% to 59%, and ≥60%. The primary outcome measure was a composite of death or heart failure hospitalization. Within each hemodynamic subtype, clinical outcomes were compared across baseline LVEF categories of <50%, 50% to 59%, and ≥60% (reference), and unadjusted and adjusted hazard ratios (aHRs) were estimated using Cox proportional hazards models. The median follow‐up period in the entire cohort was 763 days. Results LVEF <50% was associated with a greater hazard of death or heart failure hospitalization than LVEF ≥60% in all 3 subtypes of AS. LVEF 50% to 59% was associated with a greater hazard of death or heart failure hospitalization than LVEF ≥60% in LG AS with normal flow (aHR, 1.80 [95% CI, 1.35–2.40], P <0.001) and high‐gradient AS (aHR, 1.42 [95% CI, 1.13–1.79], P =0.003) with hazards comparable to those with LVEF <50% but not in LG AS with low flow (aHR, 1.13 [95% CI, 0.72–1.79], P =0.59). Conclusions These findings suggest that LVEF may provide additional prognostic stratification within severe AS phenotypes, particularly in normal‐flow LG AS. Registration URL: https://center6.umin.ac.jp ; Unique Identifier: UMIN000034169.