Pressure gradient deviation predicts outcomes in mixed aortic valve disease: a novel stratification framework
S Park, Y C K, J Y Lee, J H Son, J H Kim, E K Kim, S A Chang, S C Lee, S W ParkAbstract
Aims
Because mixed aortic valve disease (MAVD) has complex hemodynamic characteristics, grading its severity remains challenging. We propose a new approach for grading MAVD based on the deviation of mean pressure gradient (PG) from the expected value, which may better reflect the overall hemodynamic burden.
Methods and Results
Between 2008 and 2020, a total of 7,075 patients with moderate to severe aortic stenosis (AS) (aortic valve area ≤1.5 cm2) were enrolled from three tertiary centers. MAVD was defined as the presence of concomitant mild or greater aortic regurgitation (AR). Patients with isolated AS were used as the reference population to estimate expected mean PG by modeling the relationship between aortic valve area and mean PG. The primary outcome was cardiac death or hospitalization for heart failure (HHF). Among the 7,075 patients with moderate or severe AS, 3,647 (51.5%) had isolated AS and 1,677 (48.5%) had MAVD. The incidence of cardiac death or HHF was higher in the MAVD group compared with the isolated AS group (log rank p=0.032). In the MAVD group, a greater measured mean PG relative to the expected value was associated with a lower risk of cardiac death or HHF (per +10%, adjusted hazard ratio [aHR] 0.95; 95% confidence interval [CI] 0.92–0.99; p=0.004) but with a higher risk of aortic valve replacement (AVR) (aHR 1.10; 95% CI 1.08–1.13; p<0.001). These associations remained significant after adjustment for conventional AR grading. MAVD patients in the highest quartile of mean PG deviation had a risk of cardiac death or HHF comparable to those with isolated AS, but a higher risk of AVR.
Conclusions
In patients with MAVD, the directional deviation of mean PG from the expected value derived from isolated AS was independently associated with the risk of cardiac death or HHF, beyond conventional AR grading.Outcome by the deviation from ref. mean PGStratification by the mean PG deviation