Prevalence and Prognostic Implications of Discordant Grading and Flow-Gradient Patterns in Moderate Aortic Stenosis
Open accessAbstract
Background The prognostic implications of discordant grading in severe aortic stenosis (AS) are well known. However, the prevalence of different flow-gradient patterns and their prognostic implications in moderate AS are unknown.Objectives The purpose of this study was to investigate the occurrence and prognostic implications of different flow-gradient patterns in patients with moderate AS.Methods Patients with moderate AS (aortic valve area >1.0 and ≤1.5 cm 2) were identified and divided in 4 groups based on transvalvular mean gradient (MG), stroke volume index (SVi), and left ventricular ejection fraction (LVEF): concordant moderate AS (MG ≥20 mm Hg) and discordant moderate AS including 3 subgroups: normal-flow, low-gradient moderate AS (MG <20 mm Hg, SVi ≥35 mL/m 2, and LVEF ≥50%); "paradoxical" low-flow, low-gradient moderate AS (MG <20 mm Hg, SVi <35 mL/m 2, and LVEF ≥50%) and "classical" low-flow, low-gradient moderate AS (MG <20 mm Hg and LVEF <50%). The primary endpoint was all-cause mortality.Results Of 1,974 patients (age 73 ± 10 years, 51% men) with moderate AS, 788 (40%) had discordant grading, and these patients showed significantly higher mortality rates than patients with concordant moderate AS (P < 0.001). On multivariable analysis, "paradoxical" low-flow, low-gradient (HR: 1.458; 95% CI: 1.072-1.983; P = 0.014) and "classical" low-flow, low-gradient (HR: 1.710; 95% CI: 1.270-2.303; P < 0.001) patterns but not the normal-flow, low-gradient moderate AS pattern were independently associated with all-cause mortality.Conclusions Discordant grading is frequently (40%) observed in patients with moderate AS. Low-flow, low-gradient patterns account for an important proportion of the discordant cases and are associated with increased mortality. These findings underline the need for better phenotyping patients with discordant moderate AS.
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Mild versus moderate discordant grading (moderate AVA 1.0-1.5 cm2 with mild gradient <20 mm Hg) occurs frequently in patients with moderate AS (20%-40%) and is associated with worse outcomes compared with concordant moderate AS.
“Recently, it has been reported that mild versus moderate discordant grading (DG; ie, moderate AVA [1.0–1.5 cm2] with mild gradient [<20 mm Hg]) also occurs frequently in the subset of patients with moderate AS (20%–40% of patients) and is associated with worse outcomes compared with concordant moderate AS. 6 , 7”
From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [7]
Previous studies reported that 20% to 40% of patients with moderate aortic valve area had mild gradient.
“These results are consistent with previous studies reporting that 20% to 40% of patients with moderate AVA had mild gradient. 6 , 7”
From Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis (2024) · cites this paper as [7]
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- Authors
- Stassen, J., Ewe, S. H., Singh, G. K., Butcher, S. C., Hirasawa, K., Amanullah, M. R., Pio, S. M., Sin, K. Y. K., Ding, Z. P., Sia, C.-H., Chew, N. W. S., Kong, W. K. F., Poh, K. K., Leon, M. B., Pibarot, P., Delgado, V., Marsan, N. A., & Bax, J. J.
- Affiliations
- Leiden University Medical Center (NL)
- National Heart Centre Singapore (SG)
- Royal Perth Hospital (AU)
- National University Heart Centre Singapore (SG)
- Columbia University Irving Medical Center (US)
- University of Turku (FI)
- Corresponding author
- Bax, Jeroen J.
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2022-08
- Volume
- 80
- Issue
- 7
- Pages
- 666-676
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W4290724578
- Cited by
- 35
- References
- 27
- Citations by year
- 2026: 4 · 2025: 8 · 2024: 10 · 2023: 10 · 2022: 3
- FWCI
- 5.39
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, cc-by)
- Leiden Repository (Leiden University) (submittedVersion, cc-by)
- Document Server@UHasselt (UHasselt) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Valve Diseases and Treatments
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Aortic Disease and Treatment Approaches
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Keywords
- moderate aortic stenosis, low-flow low-gradient aortic stenosis, paradoxical low-flow low-gradient aortic stenosis, stroke volume index, left ventricular ejection fraction, all-cause mortality, prognosis, aortic valve area
- MeSH terms
- Aged, Aged, 80 and over, Aortic Valve, Aortic Valve Stenosis, Female, Humans, Male, Middle Aged, Prognosis, Retrospective Studies, Severity of Illness Index, Stroke Volume, Prevalence, Ventricular Function, Left, Treatment Outcome
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