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PARTNER analysis: Assessing low flow important in severe aortic stenosis
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Stroke volume index, a measure of low flow, should be included in the evaluation and therapeutic decision-making of patients with severe aortic stenosis because low flow is common in severe cases and independently predicts mortality, according to a PARTNER trial analysis.
Howard C. Herrmann, MD, with the University of Pennsylvania, Philadelphia, and colleagues analyzed results from the PARTNER trial, which randomly assigned patients with severe aortic stenosis to medical management vs. transcatheter aortic valve replacement (PARTNER cohort B or the “inoperable” cohort), or TAVR vs. surgery (PARTNER cohort A or the “high-risk” cohort).
Among 971 patients with evaluable echocardiograms (92%), there was low flow (stroke volume index [SVI], ≤35 mL/m2) in 530 patients (55%), low flow and low ejection fraction (<50%) in 225 patients (23%), and low flow, low ejection fraction and low mean gradient (<40 mm Hg) in 147 patients (15%).
Two-year mortality was significantly higher in patients with low flow compared with normal SVI (47% vs. 34%; HR=1.5; 95% CI, 1.25-1.89). In the inoperable cohort, patients with low flow had higher mortality than those with normal flow, but both groups improved with TAVR (46% vs. 76% with low flow; 38% vs. 53% with normal flow; P<.001).
In the high-risk cohort, there was no difference between TAVR and surgery.
Howard C. Herrmann
In patients with paradoxical low flow and low mean gradient, TAVR reduced 1-year mortality from 66% to 35% (HR=0.38; P=.02).
Herrmann and colleagues wrote that low flow was an independent predictor of mortality in all patient cohorts (HR roughly 1.5), whereas ejection fraction and gradient were not.
"... Stroke volume is a crucial piece of information to determine prognosis and inform treatment decisions,” they wrote. “It may be particularly important in symptomatic patients with low gradient, in whom decision-making with regard to valve replacement is more difficult.”
Disclosure: Herrmann is a consultant for Paieon and St. Jude Medical, receives equity from Micro Interventional Devices, and reports institutional research funding from Edwards Lifesciences for participation in the PARTNER trial.
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