P680Asymptomatic severe aortic stenosis: impact on clinical outcome of new proposed aortic stenosis grading classification

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Background: The management of patients with asymptomatic severe aortic valve stenosis (AS) remains controversial. Moreover, under the same denomination of severe AS, several entities may be identified according to transvalvular flow rates and pressure gradients, resulting in 4 flow-gradient patterns. We therefore studied the clinical course of patients with asymptomatic severe AS according to this new AS grading classification.Methods and Results: Transthoracic echocardiography and measurement of BNP level from venous blood sample were performed in 150 consecutive patients with asymptomatic severe AS and normal exercise test. Patients were classified in 4 groups depending on LV flow state (normal flow vs. low flow: 35ml/m2) and pressure gradient levels (low gradient vs. high gradient: 40mmHg). Patients with normal flow/low gradient (NF/LG) had significantly lower BNP than those with low flow/ high gradient (HG) and LF/LG. The mean follow-up was 27±12 months. At 2-year, cardiac event-free survival was 83±6%, 44±6%, 30±12% and 27±13% in NF/LG, NF/HG, LF/HG and LF/LG groups, respectively (p<0.0001). On multivariable analysis, LF/LG (HR=5.26, 95%CI: 2.04-14.3, p=0.045) and LF/HG (HR=2.38, 95%CI: 1.02-5.55, p=0.001) were identified as strong independent determinants of poor prognosis as compared to NF/HG. By limiting the multivariable analysis to patients with LF, LF/LG was an independent predictor of markedly reduced cardiac event-free survival when compared to LF/HG (HR=5.4, 95%CI: 1.03-28.6, p=0.046).Conclusion: The use of the new AS grading classification integrating valve area and flow-gradient patterns allows a better characterization of the clinical outcome of patients with asymptomatic severe AS.

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