Aortic valve replacement improves survival in severe aortic stenosis with gradient-area mismatch

To investigate whether and in which patients with catheter-derived low pressure gradient (PG, < 40 mmHg) severe (aortic valve area a parts per thousand<currency> 1 cm(2)) aortic stenosis and preserved left ventricular ejection fraction, early aortic valve replacement (AVR) might improve survival. We investigated a total of 506 consecutive patients (age 75 +/- 9 years, 58% men) with either moderate aortic stenosis (MAS) or severe aortic stenosis (SAS) and preserved left ventricular ejection fraction (a parts per thousand<yen>50%) as defined at catheterization. Propensity score matching was used to select matched pairs of patients with and without AVR in each group. A 100% complete follow-up of all cause death was obtained after a median of 6.6 years (interquartile range 3.4-8.8 years). There were 62 (12%) patients with MAS, 119 (24%) patients with SAS and low (< 40 mmHg) PG and 325 (64%) patients with SAS and high PG. Significantly less patients with MAS and low-gradient SAS underwent AVR compared to patients with high gradient SAS (58% vs 60% vs 83%, P < 0.001). In propensity score-matched patients, AVR was independently associated with a decrease in all-cause mortality in all groups (P < 0.05) regardless of the PG, stroke volume or aortic valve area. The present data indicate a that AVR improves survival in SAS regardless of the gradient and flow. This advocates an 'early-AVR' rather than a 'watchful waiting' strategy.