Clinical Investigations
Aortic Stenosis Assessment in Atrial Fibrillation
Doppler Mean Gradient Is Discordant to Aortic Valve Calcium Scores in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement

https://doi.org/10.1016/j.echo.2021.08.024Get rights and content

Highlights

  • MG during AF underestimated AS severity.

  • Patients with AF may be referred late for aortic valve replacement.

  • Highest MG during AF may help diagnose severe AS earlier

Background

Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR).

Methods

Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography.

Results

Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76–86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm2/m2 [IQR, 0.39–0.47 cm2/m2] vs 0.46 cm2/m2 [IQR, 0.41–0.51 cm2/m2], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803–4,030 AU] vs 2,722 AU [IQR, 2,180–3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS.

Conclusions

AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.

Section snippets

Study Population

Patients undergoing TAVR between January 1, 2016, and April 1, 2020, for native valve severe AS with LVEF ≥ 50% were identified from the Mayo Clinic TAVR and echocardiography laboratory databases. The study period was commensurate with the updated 2014 valve disease management guidelines6 and updated AS echocardiographic assessment guidelines12 and the evolving criteria for TAVR in clinical practice, including multidisciplinary heart team evaluation. Patients were divided according to rhythm

Results

A total of 633 patients were included; the median age was 82 years (IQR, 76–86 years), and 46% were women. The rhythm during the echocardiogram was SR in 524 (83%) and AF in 109 (17%) patients.

Discussion

In the present study we examined AVCS and their relationship to Doppler MGs obtained during AF versus SR in patients who were diagnosed with native valve severe AS and subsequently underwent TAVR. The major findings were that (1) AVCS were discordant to MGs obtained during AF compared with SR, especially in men, and (2) men with HGAS during AF had very high AVCS compared with their counterparts.

The diagnosis of severe AS is not in doubt in the setting a Doppler MG ≥ 40 mm Hg or peak aortic jet

Conclusion

Echocardiographic Doppler MG obtained during AF versus SR was discordant to computed tomography–determined AVCS in patients undergoing TAVR for native valve severe AS. This discordance was most pronounced in men with AF, who had very high AVCS consistent with more advanced AS compared with their counterparts. The mechanisms of the more advanced AS at the time of TAVR may be related to underestimated AS severity during progressive AS because of lower flow and/or late referral to TAVR. In the

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  • Cited by (0)

    The Department of Cardiovascular Medicine at the Mayo Clinic provided funding for data retrieval.

    Conflicts of interests: None.

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