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Background <p>The prevalence and prognostic implications of low-flow (LF) aetiologies in aortic stenosis (AS) are unknown. This study aimed to characterize the specific causes of LF, their prevalence, and prognostic significance.</p> Methods <p>In 408 patients with severe LFAS included, the aetiology of LF was identified. The primary endpoint was the composite of all-cause death and hospitalizations for heart failure (HF) up to 36&#xa0;months. Secondary endpoints included individual components of the primary endpoint and cardiovascular mortality.</p> Results <p>The most common LF cause was reduced LVEF (<i>n</i> = 228, 55.9%), while preserved LVEF included five aetiologies: (1)mixed aetiologies (<i>n</i> = 65, 36.1%), (2)small LV cavity (<i>n</i> = 58, 32.2%), (3)significant isolated mitral regurgitation (<i>n</i> = 39, 21.7%), (4)significant isolated tricuspid regurgitation (<i>n</i> = 13, 7.2%), (5)significant isolated mitral stenosis (<i>n</i> = 5, 2.8%). Over a median follow-up of 15 (IQR 6 – 36) months obtained in 302 patients, 159 (52.6%) reached the primary composite endpoint, 108 (35.8%) died and 91 (30.8%) were hospitalized due to HF. LF aetiology was not associated with outcomes. Independent predictors of the primary endpoint were severe MR (adj.HR 1.71, <i>p</i> = 0.04) and TR (adj.HR 1.47, <i>p</i> = 0.04). Aortic valve replacement (adj.HR 0.76, <i>p</i> &lt; 0.001) and mean transvalvular gradient ≥ 40&#xa0;mmHg (adj.HR 0.39, <i>p</i> &lt; 0.001) were protective.</p> Conclusions <p>The main cause of LFAS is reduced LVEF, while in preserved LVEF mixed causes and small LV volume prevailed, without association with the outcome. Severe mitral and tricuspid regurgitation were strongly associated with worse outcomes, while valve replacement and mean transvalvular gradient ≥ 40&#xa0;mmHg emerged as protective factors.</p> Graphical abstract <p>This study aimed to address unanswered questions in low-flow aortic stenosis (LF AS). In patients with preserved LVEF (paradoxical low flow), five aetiological factors were identified, with different prevalence. Survival curves showed no significant difference in the occurrence of the primary endpoint according to the LF cause. Factors independently associated with a higher risk of HF hospitalizations and all-cause mortality in LF AS were severe (4+) mitral regurgitation (MR), severe (4+) tricuspid regurgitation (TR), mean transvalvular gradient ≥40mmHg (MG, protective factor) and aortic valve intervention (protective factor). <i>LV: left ventricular; MR: mitral regurgitation; TR: tricuspid regurgitation; MS: mitral stenosis; LVEF: left ventricular ejection fraction</i></p> <p></p>

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Prevalence and prognostic implications of different aetiologies of low flow aortic stenosis

  • 期刊论文

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  • 发表日期：

    2025年12月13日

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  • Giorgio Fiore,
  • Federico Biondi,
  • Margherita Fabris,
  • Paola Cunsolo,
  • Michele Morosato,
  • Marco Gamardella,
  • Giacomo Ingallina,
  • Stefano Stella,
  • Francesco Ancona,
  • Annamaria Tavernese,
  • Davide Margonato,
  • Martina Belli,
  • Alessandro Castiglioni,
  • Matteo Montorfano,
  • Francesco Maisano,
  • Eustachio Agricola

摘要

Background

The prevalence and prognostic implications of low-flow (LF) aetiologies in aortic stenosis (AS) are unknown. This study aimed to characterize the specific causes of LF, their prevalence, and prognostic significance.

Methods

In 408 patients with severe LFAS included, the aetiology of LF was identified. The primary endpoint was the composite of all-cause death and hospitalizations for heart failure (HF) up to 36 months. Secondary endpoints included individual components of the primary endpoint and cardiovascular mortality.

Results

The most common LF cause was reduced LVEF (n = 228, 55.9%), while preserved LVEF included five aetiologies: (1)mixed aetiologies (n = 65, 36.1%), (2)small LV cavity (n = 58, 32.2%), (3)significant isolated mitral regurgitation (n = 39, 21.7%), (4)significant isolated tricuspid regurgitation (n = 13, 7.2%), (5)significant isolated mitral stenosis (n = 5, 2.8%). Over a median follow-up of 15 (IQR 6 – 36) months obtained in 302 patients, 159 (52.6%) reached the primary composite endpoint, 108 (35.8%) died and 91 (30.8%) were hospitalized due to HF. LF aetiology was not associated with outcomes. Independent predictors of the primary endpoint were severe MR (adj.HR 1.71, p = 0.04) and TR (adj.HR 1.47, p = 0.04). Aortic valve replacement (adj.HR 0.76, p < 0.001) and mean transvalvular gradient ≥ 40 mmHg (adj.HR 0.39, p < 0.001) were protective.

Conclusions

The main cause of LFAS is reduced LVEF, while in preserved LVEF mixed causes and small LV volume prevailed, without association with the outcome. Severe mitral and tricuspid regurgitation were strongly associated with worse outcomes, while valve replacement and mean transvalvular gradient ≥ 40 mmHg emerged as protective factors.

Graphical abstract

This study aimed to address unanswered questions in low-flow aortic stenosis (LF AS). In patients with preserved LVEF (paradoxical low flow), five aetiological factors were identified, with different prevalence. Survival curves showed no significant difference in the occurrence of the primary endpoint according to the LF cause. Factors independently associated with a higher risk of HF hospitalizations and all-cause mortality in LF AS were severe (4+) mitral regurgitation (MR), severe (4+) tricuspid regurgitation (TR), mean transvalvular gradient ≥40mmHg (MG, protective factor) and aortic valve intervention (protective factor). LV: left ventricular; MR: mitral regurgitation; TR: tricuspid regurgitation; MS: mitral stenosis; LVEF: left ventricular ejection fraction