Outcomes of surgical versus transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis.

Abstract

This study sought to determine the impact of surgical versus transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis. This was an observational study of consecutive aortic valve replacements for severe aortic stenosis from 2010 to 2023. Patients with low-flow, low-gradient aortic stenosis (aortic valve mean gradient <40 mm Hg and a stroke volume index <35 mL/m²) were included. Both classical (ejection fraction <50%) and paradoxical (ejection fraction ≥50%) subtypes were included. Concomitant procedures and history of aortic valve replacement were excluded. Patients were dichotomized by intervention. A total of 575 patients underwent isolated, first-time aortic valve replacement for low-flow, low-gradient aortic stenosis, of whom 248 (43%) were low operative risk (Society of Thoracic Surgeons Predicted Risk of Mortality <4%). A total of 131 patients (52.8%) underwent surgical aortic valve replacement, and 117 patients (47.2%) underwent transcatheter aortic valve replacement. Those undergoing transcatheter aortic valve replacement were older than those undergoing surgical aortic valve replacement: 79.0 [76.0-84.0] years versus 66.0 [59.0-73.0] years (P < .001). The incidence of 30-day mortality, stroke, and pacemaker was not different across each group, but the incidence of paravalvular leak was higher in the transcatheter aortic valve replacement group. At 1-year follow-up, aortic valve mean gradient (9.0 [7.0-12.0] mm Hg) and ejection fraction (55.0% [40.0-60.0]) were no different across each group. On multivariable analysis, transcatheter aortic valve replacement was not associated with an increased hazard of death compared with surgical aortic valve replacement (hazard ratio, 1.38, 95% CI, 0.72-2.66, P = .34) or an increased hazard of heart failure readmission (hazard ratio, 1.70, 95% CI, 0.88-3.30, P = .11) compared with surgical aortic valve replacement. For patients with low-flow, low-gradient aortic stenosis, surgical and transcatheter approaches to aortic valve replacement may be equally as advantageous with respect to long-term outcomes.