Transvalvular Flow Rate Determines Prognostic Value of Aortic Valve Area in Aortic Stenosis

Overview

Journal J Am Coll Cardiol

Specialty Cardiology & Vascular Diseases

Date 2020 Apr 18

PMID 32299587

Citations 21

Authors

Mayooran Namasivayam

Wei He

Timothy W Churchill

Romain Capoulade

Shiying Liu

Hang Lee

Jacqueline S Danik

Michael H Picard

Philippe Pibarot

Robert A Levine

Judy Hung

Affiliations

Soon will be listed here.

Abstract

Background: Aortic valve area (AVA) ≤1.0 cm is a defining characteristic of severe aortic stenosis (AS). AVA can be underestimated at low transvalvular flow rate. Yet, the impact of flow rate on prognostic value of AVA ≤1.0 cm is unknown and is not incorporated into AS assessment.

Objectives: This study aimed to evaluate the effect of flow rate on prognostic value of AVA in AS.

Methods: In total, 1,131 patients with moderate or severe AS and complete clinical follow-up were included as part of a longitudinal database. The effect of flow rate (ratio of stroke volume to ejection time) on prognostic value of AVA ≤1.0 cm for time to death was evaluated, adjusting for confounders. Sensitivity analysis was performed to identify the optimal cutoff for prognostic threshold of AVA. The findings were validated in a separate external longitudinal cohort of 939 patients.

Results: Flow rate had a significant effect on prognostic value of AVA. AVA ≤1.0 cm was not prognostic for mortality (p = 0.15) if AVA was measured at flow rates below median (≤242 ml/s). In contrast, AVA ≤1.0 cm was highly prognostic for mortality (p = 0.003) if AVA was measured at flow rates above median (>242 ml/s). Findings were irrespective of multivariable adjustment for age, sex, and surgical/transcatheter aortic valve replacement (as time-dependent covariates); comorbidities; medications; and echocardiographic features. AVA ≤1.0 cm was also not an independent predictor of mortality below median flow rate in the validation cohort. The optimal flow rate cutoff for prognostic threshold was 210 ml/s.

Conclusions: Transvalvular flow rate determines prognostic value of AVA in AS. AVA measured at low flow rate is not a good prognostic marker and therefore not a good diagnostic marker for truly severe AS. Flow rate assessment should be incorporated into clinical diagnosis, classification, and prognosis of AS.

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