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Brain & Heart TAVR in low gradient aortic stenosis

Structural causes of BVD include intrinsic alterations gradient patterns, the cLFLGAS group showed worse
to the valve, such as leaflet wear and tear, disruption, outcomes compared with the HGAS group with higher
flail leaflets, leaflet fibrosis/calcification, and stent/strut rates of mortality, rehospitalization, or stroke. In patients
fracture. Extrinsic structural causes of BVD include with pLFLGAS, outcomes were comparable to those in
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endocarditis and thrombosis. Endocarditis occurs at the HGAS group. Compared with patients with LFLGAS
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the rate of 0.3 – 2.0/100 person-years with 16% – 64% and normal EF and those with HGAS, patients with
in-hospital morality, 27% – 75% 1-year mortality, and LFLGAS and low EF exhibited considerably higher rates
>60% 5-year mortality. Up to 70% of patients experienced of all-cause mortality, major stroke, and cardiovascular
complications such as MI, acute HF, acute renal failure, mortality based on early outcomes at 30 days after TAVR.
septic shock, and abscesses. 59,60 Antimicrobial prophylaxis However, the NYHA functional classification and KCC Q
is implemented to mitigate endocarditis. Management scores improved in all the groups at 1 year. In a subgroup
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includes antibiotic therapy and surgical explantation if analysis of the German aortic valve registry, patients
there is severe valve dysfunction, refractory heart failure, with cLFLGAS exhibited higher 1-year mortality rates
uncontrolled infection, perivalvular infection, or high after TAVR than those with HGAS. These patients also
embolic risk. 61 demonstrated significantly lower post-operative cardiac
Thrombosis is identified by hypoattenuated leaflet output. Patients with pLFLGAS exhibited outcomes
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thickening on CT. Clinical thrombosis occurred in 0.6% similar to those with HGAS. An observational study in
– 2.8% of cases. 62,63 Subclinical thrombosis is significantly Japan found that pLFLGAS was associated with an increase
more prevalent, with a prevalence of 10% – 15% at 30 days in all-cause mortality compared to HGAS, 8.8 months after
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and 30% at 1 year. 64-66 Prevention of subclinical thrombosis TAVR. When 1-year survival outcomes of HGAS versus
has not yet been elucidated. Conflicting evidence exists LFLGAS were compared in matched study populations
regarding the clinical implications of subclinical leaflet after TAVR, patients with cLFLGAS showed a twofold
thrombosis and the existence of elevated rates of subclinical increase in mortality compared with those with HGAS.
leaflet thrombosis in patients with cLFLGAS. 67-69 However, when patients with pLFLGAS were specifically
compared with those with HGAS, survival outcomes were
7. Outcomes similar. Another observational study comparing post-
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Overall, TAVR has been demonstrated to be beneficial TAVR outcomes of pLFLGAS with HGAS revealed worse
for patients with LGAS. The PARTNER trial, which all-cause mortality, valve-related or worsening congestive
assessed patients with pLFLGAS 1 year following TAVR, heart failure-related hospitalizations, and more frequent
demonstrated a decrease in mortality from 66% to 35% in NYHA III – IV symptoms in patients with pLFLGAS
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the pLFLGAS group. (Table 2). In a multicenter registry than in those with HGAS. The outcomes of 270 patients
(TOPAS-TAVI) of 287 patients, patients with cLFLGAS with severe AS and low EF were compared in 2012 and
undergoing TAVR were studied. Notably, 1-year post- stratified by valvular gradient. Patients with low gradients
TAVR, LVEF incidence increased by 8.3%. Mortality were more frequently treated medically (21% underwent
was observed in 32.3% of these patients at the 2-year TAVR or SAVR), whereas those with HGAS underwent
follow-up. A sub-study of the same registry compared TAVR more frequently. Patients with cLFLGAS had a
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outcomes between patients with very low (<30%) and low mortality rate of 53.8% at 151 days compared with 41%
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(30% – 40%) EF undergoing TAVR. Irrespective of the in patients with HG. A meta-analysis demonstrated that
LVEF severity and dobutamine stress echo results, TAVR patients with LGAS showed a higher 30-day, midterm
was associated with a significant increase in LVEF with all-cause, and cardiovascular mortality than those with
comparable outcomes in both groups. A meta-analysis of HGAS after TAVR, with similar outcomes among patients
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SAVR and TAVR in patients with LFLGAS demonstrated with cLFLGAS and pLFLGAS. Another meta-analysis
that both significantly reduced all-cause mortality, with no demonstrated that cLFLGAS was associated with increased
differences among the approaches. In a meta-analysis, early mortality compared with HGAS. Both cLFLGAS
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AVR (SAVR or TAVR) was demonstrated to enhance and pLFLGAS demonstrated elevated midterm mortality
mortality in patients with cLFLGAS and NFLGAS. 73 compared with the HGAS. 88
7.1. LGAS versus HGAS 7.2. AVR versus medical management

Numerous studies have compared the outcomes in In studies comparing AVR with conservative management,
LFLGAS and its subtypes with HGAS after TAVR. When AVR exhibited a proven benefit. In a clinical trial,
the 2-year post-AVR (TAVR or SAVR) outcomes of patients outcomes were compared in patients with cLFLGAS who
of the PARTNER 2 trial were analyzed according to flow underwent TAVR, SAVR, or medical therapy. TAVR and

Volume 3 Issue 1 (2025) 10 doi: 10.36922/bh.4017