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This study sought to determine the incidence, clinical impact, and changes over time of mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR). Few data exist on the clinical impact and changes in severity over time of MR in patients with LFLG-AS undergoing TAVR. A total of 308 TAVR candidates with LFLG-AS were included. Patients were categorized according to MR severity at baseline, and presence of MR improvement at 12-month follow-up. Clinical outcomes were assessed at 1 and 12 months (+ echocardiography), and yearly thereafter. Baseline mild and moderate-to-severe MR were present in 118 (38.3%) and 115 (37.3%) patients, respectively. MR was of functional and mixed etiology in 77.2% and 22.7% of patients, respectively. A total of 131 patients (42.5%) died after a median follow-up of 2 (1 to 3) years. Baseline moderate-or-greater MR had no impact on mortality (hazard ratio [HR]: 1.34; 95% confidence interval [CI]: 0.72 to 2.48) or heart failure hospitalization (HR: 1.02; 95% CI: 0.49 to 2.10). At 1-year follow-up, MR improved in 44.3% of patients and remained unchanged/worsened in 55.7%. The lack of MR improvement was associated with a higher risk of all-cause and cardiac mortality (HR: 2.02; 95% CI: 1.29 to 3.17; HR: 3.03; 95% CI: 1.27 to 7.23, respectively), rehospitalization for cardiac causes (HR: 1.50; 95% CI: 1.04 to 2.15), and an increased overall-mortality/heart failure rehospitalization (HR: 1.94; 95% CI: 1.25 to 3.02). A higher baseline left ventricular end-diastolic diameter and a higher increase in left ventricular ejection fraction were found to be independent predictors of MR improvement at 1-year follow-up (odds ratio: 0.69; 95% CI: 0.51 to 0.94; and odds ratio: 0.81; 95% CI: 0.67 to 0.96, respectively). Most TAVR candidates with LFLG-AS had some degree of MR, of functional origin in most cases. MR improved in about one-half of patients, with larger left ventricular size and a higher increase in left ventricular ejection fraction post-TAVR determining MR improvement over time. The lack of MR improvement at 1 year was associated with poorer outcomes.

Few data exist on patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR). Also, very scarce data exist on the usefulness of dobutamine stress echocardiography (DSE) before TAVR in these patients.The authors sought to evaluate clinical outcomes and changes in left ventricular ejection fraction (LVEF) following TAVR in patients with classical LFLG-AS.This multicenter registry included 287 patients with LFLG-AS undergoing TAVR. DSE was performed before TAVR in 234 patients and the presence of contractile reserve was defined as an increase of ≥20% in stroke volume. Transthoracic echocardiography was repeated at hospital discharge and at 1-year follow-up. Clinical follow-up was obtained at 1 and 12 months, and yearly thereafter.The median Society of Thoracic Surgeons score of the study population was 7.7% (interquartile range 5.3% to 12.0%), and the mean LVEF and transvalvular gradient were 30.1 ± 9.7% and 25.4 ± 6.6 mm Hg, respectively. The presence of contractile reserve was observed in 45% of patients at DSE. Mortality rates were 3.8%, 20.1%, and 32.3% at 30 days, 1 year, and 2 years, respectively. On multivariable analysis, chronic obstructive pulmonary disease (p = 0.022) and lower hemoglobin values (p 0.001) were associated with all-cause mortality. Lower hemoglobin values (p = 0.004) and moderate-to-severe aortic regurgitation post-TAVR (p = 0.018) were predictors of the composite of mortality and rehospitalization due to heart failure. LVEF increased by 8.3% (95% confidence interval: 6% to 11%) at 1-year follow-up, and the lack of prior coronary artery bypass graft (p = 0.004), a lower LVEF at baseline (p 0.001), and a lower stroke volume index at baseline (p = 0.019) were associated with greater increase in LVEF. The absence of contractile reserve at baseline DSE was not associated with any negative effect on clinical outcomes or LVEF changes at follow-up.TAVR was associated with good periprocedural outcomes in patients with LFLG-AS. However, approximately one-third of LFLG-AS TAVR recipients died at 2-year follow-up, with pulmonary disease, anemia, and residual paravalvular leaks associated with poorer outcomes. LVEF improved following TAVR, but DSE failed to predict clinical outcomes or LVEF changes over time. (Multicenter Prospective Study of Low-Flow Low-Gradient Aortic Stenosis [TOPAS Study]; NCT01835028).

Introduction: The prevalence and impact of pulmonary hypertension (PH) severity on clinical outcomes for patients with severe AS is unclear and controversial. Our goal was to compare the correlation of mortality to degree of PH as measured by transthoracic echocardiography (ECHO) versus invasive hemodynamics (CATH). Methods: Retrospective data collection of patients with severe aortic stenosis (AV area index ≤ 0.6 cm2/m2) and measured pulmonary artery systolic pressure (PASP) by ECHO and CATH within 60 days of one another from 2010-2014. According to guidelines, patients were classified as having no PH (PASP Results: A total of 186 patients were identified with mean age of 77 ± 10 years, 62% male and 38% diabetic. The median time difference between the 2 procedures was 4 days (IQR: 1-13 days). After a median follow-up of 18 months (IQR: 5-27 months), there were 63 deaths (34%). Moderate/Severe PH was prevalent by either ECHO or CATH (47% vs. 62%, p Conclusions: Moderate or greater PH is common among severe AS patients and is more commonly diagnosed by CATH. Ascertainment of PH severity by CATH is important as even moderate PH correlates with increased 1-yr mortality despite adjustment for AVR and other comorbidities.

Introduction: Pulmonary hypertension (PH) may arise from both pre-capillary and post-capillary etiologies which can be evaluated and quantified by invasive hemodynamics (CATH). The impact of PH etiology on all-cause mortality of patients with severe aortic stenosis (AS) is unknown. Hypothesis: CATH classification of PH etiology allows for identification of severe AS patients with combined pre and post-capillary PH that would have the highest mortality risk. Methods: Retrospective data collection of patients with severe AS (AV area index ≤ 0.6 cm2/m2) and CATH with invasive hemodynamics was performed. Patients were classified as having: a) no PH (PAmean Results: A total of 187 patients were identified with mean age of 77 ± 10 years, 62% male and 38% diabetic. After a median follow-up of 18 months (IQR: 5-27 months), there were 66 deaths (35%). According to the etiology, 54 patients (29%) had no PH, 18 (10%) had PAH, 78 (42%) had passive PH, and 37 (20%) had combined PH. After adjustments for AVR (HR=0.14, 95% CI 0.05-0.35,p Conclusion: Post-capillary PH is very common in severe AS (62%). Ascertainment of PH etiology by CATH is important as combined pre-post capillary PH is associated with increased short-term mortality despite adjustments for AVR and other comorbidities. Whether this risk can be decreased by further interventions needs to be investigated in future studies.

Background: The use of intravenous adenosine to help differentiate the origin of tachyarrhythmias has been suggested to be beneficial. However, the benefit of this intervention to physicians with different levels of training in electrocardiographic (ECG) interpretation is unknown. Hypothesis: The purpose of the study was to determine whether intravenous adenosine improved the diagnostic accuracy of difficult to diagnose tachyarrhythmias when used by physicians with different levels of training in ECG interpretation. Methods: We studied 28 consecutive patients presenting with wide and narrow complex tachyarrhythmias, in whom adenosine was given specifically for diagnostic purposes. Two groups of physicians, attending (n = 14) and housestaff (n = 10), reviewed each ECG before and after the administration of adenosine. Results: For narrow complex tachyarrhythmias, neither physician group derived diagnostic benefit from the use of adenosine. However, for wide complex tachyarrhythmias, the diagnostic accuracy of the housestaff group significantly improved with the use of adenosine (pre = 54%, post = 70%, p < 0.01), while the attending physician group had no significant improvement (pre = 61%, post = 71%, p = NS). Conclusion: This study suggests that adenosine provides useful diagnostic information to physicians less experienced in ECG interpretation when presented with patients having wide complex tachyarrhythmias of uncertain origin.