Discordant severity criteria in patients with moderate aortic stenosis: Prognostic implications

Stephan M. Pio; Mohammed R. Amanullah; Steele C. Butcher; Kenny Y. Sin; Nina Ajmone Marsan; Philippe Pibarot; Nicolas M. Van Mieghem; Zee Pin Ding; Philippe Généreux; Martin B. Leon; See Hooi Ewe; Victoria Delgado; Jeroen J. Bax

doi:10.1136/openhrt-2021-001639

Discordant severity criteria in patients with moderate aortic stenosis: Prognostic implications

Stephan M. Pio, Mohammed R. Amanullah, Steele C. Butcher, Kenny Y. Sin, Nina Ajmone Marsan, Philippe Pibarot, Nicolas M. Van Mieghem, Zee Pin Ding, Philippe Généreux, Martin B. Leon, See Hooi Ewe, Victoria Delgado, Jeroen J. Bax^*

^*Corresponding author for this work

Cardiology

Research output: Contribution to journal › Article › Academic › peer-review

13 Citations (Scopus)

Abstract

Background The criteria to define the grade of aortic stenosis (AS) - aortic valve area (AVA) and mean gradient (MG) or peak jet velocity - do not always coincide into one grade. Although in severe AS, this discrepancy is well characterised, in moderate AS, the phenomenon of discordant grading has not been investigated and its prognostic implications are unknown. Objectives To investigate the occurrence of discordant grading in patients with moderate AS (defined by an AVA between 1.0 cm² and 1.5 cm² but with an MG <20 mm Hg) and how these patients compare with those with concordant grading moderate AS (AVA between 1.0 cm² and 1.5 cm² and MG ≥20 mm Hg) in terms of clinical outcomes. Methods From an ongoing registry of patients with AS, patients with moderate AS based on AVA were selected and classified into discordant or concordant grading (MG <20 mm Hg or ≥20 mm Hg, respectively). The clinical endpoint was all-cause mortality. Results Of 790 patients with moderate AS, 150 (19.0%) had discordant grading, moderate AS. Patients with discordant grading were older, had higher prevalence of previous myocardial infarction and left ventricular (LV) hypertrophy, larger LV end-diastolic and end-systolic volume index, higher LV filling pressure and lower LV ejection fraction and stroke volume index as compared with their counterparts. After a median follow-up of 4.9 years (IQR 3.0-8.2), patients with discordant grading had lower aortic valve replacement rates (26.7% vs 44.1%, p<0.001) and higher mortality rates (60.0% vs 43.1%, p<0.001) as compared with patients with concordant grading. Discordant grading moderate AS, combined with low LV ejection fraction, presented the higher risk of mortality (HR 2.78 (2.00-3.87), p<0.001). Conclusion Discordant-grading moderate AS is not uncommon and, when combined with low LV ejection fraction, is associated with high risk of mortality.

Original language	English
Article number	e001639
Journal	Open Heart
Volume	8
Issue number	1
DOIs	https://doi.org/10.1136/openhrt-2021-001639
Publication status	Published - 22 Jun 2021

Bibliographical note

Funding Information:
Competing interests The Department of Cardiology, Heart Lung Center, Leiden University Medical Center has received grants from Biotronik, Medtronic, Boston Scientific, GE Healthcare, and Edwards Lifesciences. NAM has received speaker fees from Abbott and Philips Ultrasound. ZPD has received speaker fees from Philips. PP has received grant support from Edwards Lifesciences and Medtronic. SHE has received speaker fees from Edwards Lifesciences and Abbott Vascular. VD has received speaker fees from Abbott Vascular. JJB has received speaker fees from Abbott Vascular and Boehringer Ingelheim. PG reports speaker fee from Edwards Lifesciences, Cordis, Medtronic; Consultant: Abiomed, Boston Scientific, Cardiovascular System Inc., Cordis, Edwards Lifesciences, Medtronic, Opsens, Soundbite Medical Solutions Inc., Pi-Cardia, Saranas, Siemens, Shockwave Medical Inc., SIG.NUM; Teleflex, 4C Medical, Shareholder: Soundbite Medical Solutions Inc., SIG.NUM, Pi-Cardia, Puzzle Medical. MBL is an early physician founder of Mitralign and has an equity relationship (< 1% of the company).

Funding Information:
Funding SMP received funding from European Society of Cardiology in form of an ESC Training Grant (the reference of application number is T-2018-17405).

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©

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10.1136/openhrt-2021-001639

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Pio, S. M., Amanullah, M. R., Butcher, S. C., Sin, K. Y., Ajmone Marsan, N., Pibarot, P., Van Mieghem, N. M., Ding, Z. P., Généreux, P., Leon, M. B., Ewe, S. H., Delgado, V., & Bax, J. J. (2021). Discordant severity criteria in patients with moderate aortic stenosis: Prognostic implications. Open Heart, 8(1), Article e001639. https://doi.org/10.1136/openhrt-2021-001639

@article{1afb1d9ffc214c519617c4548c73607b,

title = "Discordant severity criteria in patients with moderate aortic stenosis: Prognostic implications",

abstract = "Background The criteria to define the grade of aortic stenosis (AS) - aortic valve area (AVA) and mean gradient (MG) or peak jet velocity - do not always coincide into one grade. Although in severe AS, this discrepancy is well characterised, in moderate AS, the phenomenon of discordant grading has not been investigated and its prognostic implications are unknown. Objectives To investigate the occurrence of discordant grading in patients with moderate AS (defined by an AVA between 1.0 cm² and 1.5 cm² but with an MG <20 mm Hg) and how these patients compare with those with concordant grading moderate AS (AVA between 1.0 cm² and 1.5 cm² and MG ≥20 mm Hg) in terms of clinical outcomes. Methods From an ongoing registry of patients with AS, patients with moderate AS based on AVA were selected and classified into discordant or concordant grading (MG <20 mm Hg or ≥20 mm Hg, respectively). The clinical endpoint was all-cause mortality. Results Of 790 patients with moderate AS, 150 (19.0%) had discordant grading, moderate AS. Patients with discordant grading were older, had higher prevalence of previous myocardial infarction and left ventricular (LV) hypertrophy, larger LV end-diastolic and end-systolic volume index, higher LV filling pressure and lower LV ejection fraction and stroke volume index as compared with their counterparts. After a median follow-up of 4.9 years (IQR 3.0-8.2), patients with discordant grading had lower aortic valve replacement rates (26.7% vs 44.1%, p<0.001) and higher mortality rates (60.0% vs 43.1%, p<0.001) as compared with patients with concordant grading. Discordant grading moderate AS, combined with low LV ejection fraction, presented the higher risk of mortality (HR 2.78 (2.00-3.87), p<0.001). Conclusion Discordant-grading moderate AS is not uncommon and, when combined with low LV ejection fraction, is associated with high risk of mortality. ",

author = "Pio, {Stephan M.} and Amanullah, {Mohammed R.} and Butcher, {Steele C.} and Sin, {Kenny Y.} and {Ajmone Marsan}, Nina and Philippe Pibarot and {Van Mieghem}, {Nicolas M.} and Ding, {Zee Pin} and Philippe G{\'e}n{\'e}reux and Leon, {Martin B.} and Ewe, {See Hooi} and Victoria Delgado and Bax, {Jeroen J.}",

note = "Funding Information: Competing interests The Department of Cardiology, Heart Lung Center, Leiden University Medical Center has received grants from Biotronik, Medtronic, Boston Scientific, GE Healthcare, and Edwards Lifesciences. NAM has received speaker fees from Abbott and Philips Ultrasound. ZPD has received speaker fees from Philips. PP has received grant support from Edwards Lifesciences and Medtronic. SHE has received speaker fees from Edwards Lifesciences and Abbott Vascular. VD has received speaker fees from Abbott Vascular. JJB has received speaker fees from Abbott Vascular and Boehringer Ingelheim. PG reports speaker fee from Edwards Lifesciences, Cordis, Medtronic; Consultant: Abiomed, Boston Scientific, Cardiovascular System Inc., Cordis, Edwards Lifesciences, Medtronic, Opsens, Soundbite Medical Solutions Inc., Pi-Cardia, Saranas, Siemens, Shockwave Medical Inc., SIG.NUM; Teleflex, 4C Medical, Shareholder: Soundbite Medical Solutions Inc., SIG.NUM, Pi-Cardia, Puzzle Medical. MBL is an early physician founder of Mitralign and has an equity relationship (< 1% of the company). Funding Information: Funding SMP received funding from European Society of Cardiology in form of an ESC Training Grant (the reference of application number is T-2018-17405). Publisher Copyright: {\textcopyright} ",

year = "2021",

month = jun,

day = "22",

doi = "10.1136/openhrt-2021-001639",

language = "English",

volume = "8",

journal = "Open Heart",

issn = "2398-595X",

publisher = "BMJ Publishing Group",

number = "1",

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TY - JOUR

T1 - Discordant severity criteria in patients with moderate aortic stenosis

T2 - Prognostic implications

AU - Pio, Stephan M.

AU - Amanullah, Mohammed R.

AU - Butcher, Steele C.

AU - Sin, Kenny Y.

AU - Ajmone Marsan, Nina

AU - Pibarot, Philippe

AU - Van Mieghem, Nicolas M.

AU - Ding, Zee Pin

AU - Généreux, Philippe

AU - Leon, Martin B.

AU - Ewe, See Hooi

AU - Delgado, Victoria

AU - Bax, Jeroen J.

N1 - Funding Information: Competing interests The Department of Cardiology, Heart Lung Center, Leiden University Medical Center has received grants from Biotronik, Medtronic, Boston Scientific, GE Healthcare, and Edwards Lifesciences. NAM has received speaker fees from Abbott and Philips Ultrasound. ZPD has received speaker fees from Philips. PP has received grant support from Edwards Lifesciences and Medtronic. SHE has received speaker fees from Edwards Lifesciences and Abbott Vascular. VD has received speaker fees from Abbott Vascular. JJB has received speaker fees from Abbott Vascular and Boehringer Ingelheim. PG reports speaker fee from Edwards Lifesciences, Cordis, Medtronic; Consultant: Abiomed, Boston Scientific, Cardiovascular System Inc., Cordis, Edwards Lifesciences, Medtronic, Opsens, Soundbite Medical Solutions Inc., Pi-Cardia, Saranas, Siemens, Shockwave Medical Inc., SIG.NUM; Teleflex, 4C Medical, Shareholder: Soundbite Medical Solutions Inc., SIG.NUM, Pi-Cardia, Puzzle Medical. MBL is an early physician founder of Mitralign and has an equity relationship (< 1% of the company). Funding Information: Funding SMP received funding from European Society of Cardiology in form of an ESC Training Grant (the reference of application number is T-2018-17405). Publisher Copyright: ©

PY - 2021/6/22

Y1 - 2021/6/22

N2 - Background The criteria to define the grade of aortic stenosis (AS) - aortic valve area (AVA) and mean gradient (MG) or peak jet velocity - do not always coincide into one grade. Although in severe AS, this discrepancy is well characterised, in moderate AS, the phenomenon of discordant grading has not been investigated and its prognostic implications are unknown. Objectives To investigate the occurrence of discordant grading in patients with moderate AS (defined by an AVA between 1.0 cm² and 1.5 cm² but with an MG <20 mm Hg) and how these patients compare with those with concordant grading moderate AS (AVA between 1.0 cm² and 1.5 cm² and MG ≥20 mm Hg) in terms of clinical outcomes. Methods From an ongoing registry of patients with AS, patients with moderate AS based on AVA were selected and classified into discordant or concordant grading (MG <20 mm Hg or ≥20 mm Hg, respectively). The clinical endpoint was all-cause mortality. Results Of 790 patients with moderate AS, 150 (19.0%) had discordant grading, moderate AS. Patients with discordant grading were older, had higher prevalence of previous myocardial infarction and left ventricular (LV) hypertrophy, larger LV end-diastolic and end-systolic volume index, higher LV filling pressure and lower LV ejection fraction and stroke volume index as compared with their counterparts. After a median follow-up of 4.9 years (IQR 3.0-8.2), patients with discordant grading had lower aortic valve replacement rates (26.7% vs 44.1%, p<0.001) and higher mortality rates (60.0% vs 43.1%, p<0.001) as compared with patients with concordant grading. Discordant grading moderate AS, combined with low LV ejection fraction, presented the higher risk of mortality (HR 2.78 (2.00-3.87), p<0.001). Conclusion Discordant-grading moderate AS is not uncommon and, when combined with low LV ejection fraction, is associated with high risk of mortality.

AB - Background The criteria to define the grade of aortic stenosis (AS) - aortic valve area (AVA) and mean gradient (MG) or peak jet velocity - do not always coincide into one grade. Although in severe AS, this discrepancy is well characterised, in moderate AS, the phenomenon of discordant grading has not been investigated and its prognostic implications are unknown. Objectives To investigate the occurrence of discordant grading in patients with moderate AS (defined by an AVA between 1.0 cm² and 1.5 cm² but with an MG <20 mm Hg) and how these patients compare with those with concordant grading moderate AS (AVA between 1.0 cm² and 1.5 cm² and MG ≥20 mm Hg) in terms of clinical outcomes. Methods From an ongoing registry of patients with AS, patients with moderate AS based on AVA were selected and classified into discordant or concordant grading (MG <20 mm Hg or ≥20 mm Hg, respectively). The clinical endpoint was all-cause mortality. Results Of 790 patients with moderate AS, 150 (19.0%) had discordant grading, moderate AS. Patients with discordant grading were older, had higher prevalence of previous myocardial infarction and left ventricular (LV) hypertrophy, larger LV end-diastolic and end-systolic volume index, higher LV filling pressure and lower LV ejection fraction and stroke volume index as compared with their counterparts. After a median follow-up of 4.9 years (IQR 3.0-8.2), patients with discordant grading had lower aortic valve replacement rates (26.7% vs 44.1%, p<0.001) and higher mortality rates (60.0% vs 43.1%, p<0.001) as compared with patients with concordant grading. Discordant grading moderate AS, combined with low LV ejection fraction, presented the higher risk of mortality (HR 2.78 (2.00-3.87), p<0.001). Conclusion Discordant-grading moderate AS is not uncommon and, when combined with low LV ejection fraction, is associated with high risk of mortality.

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U2 - 10.1136/openhrt-2021-001639

DO - 10.1136/openhrt-2021-001639

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VL - 8

JO - Open Heart

JF - Open Heart

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ER -

Discordant severity criteria in patients with moderate aortic stenosis: Prognostic implications

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