title: Predictors of mortality and outcomes of therapy in low-flow severe aortic stenosis: a Placement of Aortic Transcatheter Valves (PARTNER) trial analysis.
abstract: BACKGROUND
  The prognosis and treatment of patients with low-flow (LF) severe aortic stenosis are controversial.
  
  
  RESULTS
  The Placement of Aortic Transcatheter Valves (PARTNER) trial randomized patients with severe aortic stenosis to medical management versus transcatheter aortic valve replacement (TAVR; inoperable cohort) and surgical aortic valve replacement versus TAVR (high-risk cohort). Among 971 patients with evaluable echocardiograms (92%), LF (stroke volume index ≤35 mL/m(2)) was observed in 530 (55%); LF and low ejection fraction (<50%) in 225 (23%); and LF, low ejection fraction, and low mean gradient (<40 mm Hg) in 147 (15%). Two-year mortality was significantly higher in patients with LF compared with those with normal stroke volume index (47% versus 34%; hazard ratio, 1.5; 95% confidence interval, 1.25-1.89; P=0.006). In the inoperable cohort, patients with LF had higher mortality than those with normal flow, but both groups improved with TAVR (46% versus 76% with LF and 38% versus 53% with normal flow; P<0.001). In the high-risk cohort, there was no difference between TAVR and surgical aortic valve replacement. In patients with paradoxical LF and low gradient (preserved ejection fraction), TAVR reduced 1-year mortality from 66% to 35% (hazard ratio, 0.38; P=0.02). LF was an independent predictor of mortality in all patient cohorts (hazard ratio, ≈1.5), whereas ejection fraction and gradient were not.
  
  
  CONCLUSIONS
  LF is common in severe aortic stenosis and independently predicts mortality. Survival is improved with TAVR compared with medical management and similar with TAVR and surgical aortic valve replacement. A measure of flow (stroke volume index) should be included in the evaluation and therapeutic decision making of patients with severe aortic stenosis.
  
  
  BACKGROUND
  URL: http://www.clinicaltrial.gov. Unique identifier: NCT0053089.4.
authors: Interventional Cardiology Program, Hospital of the University of Pennsylvania, 9038 Gates Pavilion, 3400 Spruce St, Philadelphia, PA 19104, USA. Howard.herrmann@uphs.upenn.edu
authors: Howard C
authors: HC
authors: Herrmann
authors: Philippe
authors: P
authors: Pibarot
authors: Irene
authors: I
authors: Hueter
authors: Zachary M
authors: ZM
authors: Gertz
authors: William J
authors: WJ
authors: Stewart
authors: Samir
authors: S
authors: Kapadia
authors: E Murat
authors: EM
authors: Tuzcu
authors: Vasilis
authors: V
authors: Babaliaros
authors: Vinod
authors: V
authors: Thourani
authors: Wilson Y
authors: WY
authors: Szeto
authors: Joseph E
authors: JE
authors: Bavaria
authors: Susheel
authors: S
authors: Kodali
authors: Rebecca T
authors: RT
authors: Hahn
authors: Mathew
authors: M
authors: Williams
authors: D Craig
authors: DC
authors: Miller
authors: Pamela S
authors: PS
authors: Douglas
authors: Martin B
authors: MB
authors: Leon
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000473:pathology / Q000503:physiopathology; D001024:Aortic Valve Stenosis / Q000150:complications / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001705:Bioprosthesis; D001783:Blood Flow Velocity; D006328:Cardiac Catheterization; D057510:Endovascular Procedures; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D009929:Organ Size; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012720:Severity of Illness Index; D013318:Stroke Volume; D016896:Treatment Outcome; D014463:Ultrasonography; D018487:Ventricular Dysfunction, Left / Q000150:complications / Q000503:physiopathology; D020257:Ventricular Remodeling
keywords: aortic valve stenosis; blood flow velocity; heart valves