Energy Loss Index and Dimensionless Index Outperform Direct Valve Planimetry in Low-Gradient Aortic Stenosis

Author:

Hugelshofer Sarah1ORCID,de Brito Diana1,Antiochos Panagiotis12ORCID,Tzimas Georgios1,Rotzinger David C.23ORCID,Auberson Denise1,Vella Agnese1ORCID,Fournier Stephane12,Kirsch Matthias24ORCID,Muller Olivier12,Monney Pierre12ORCID

Affiliation:

1. Service de Cardiologie, University Hospital of Lausanne (CHUV), 1011 Lausanne, Switzerland

2. Faculty of Biology and Medicine, University of Lausanne (Unil), 1011 Lausanne, Switzerland

3. Service de Radiodiagnostic et Radiologie Interventionnelle, University Hospital of Lausanne (CHUV), 1011 Lausanne, Switzerland

4. Service de Chirurgie Cardiaque, University Hospital of Lausanne (CHUV), 1011 Lausanne, Switzerland

Abstract

Background/Objectives: Among patients with suspected severe aortic stenosis (AS), discordance between effective orifice area (EOA) and transvalvular gradients is frequent and requires a multiparametric workup including flow assessment and calcium-scoring to confirm true severe AS. The aim of this study was to assess direct planimetry, energy loss index (Eli) and dimensionless index (DI) as stand-alone parameters to identify non-severe AS in discordant cases. Methods: In this prospective cohort study, we included consecutive AS patients > 70 years with EOA < 1.0 cm2 referred for valve replacement between 2014 and 2017. AS severity was retrospectively reassessed using the multiparametric work-up recommended in the 2021 ESC/EACTS guidelines. DI and ELi were calculated, and valve area was measured by direct planimetry on transesophageal echocardiography. Results: A total of 101 patients (mean age 82 y; 57% male) were included. Discordance between EOA and gradients was observed in 46% and non-severe AS found in 24% despite an EOA < 1 cm2. Valve planimetry performed poorly, with an area under the ROC curve (AUC) of 0.64. At a cut-off value of >0.82 cm2, sensitivity and specificity to identify non-severe AS were 67 and 66%, respectively. DI and ELi showed a higher diagnostic accuracy, with an AUC of 0.77 and 0.76, respectively. Cut-off values of >0.24 and >0.6 cm2/m2 identified non-severe AS, with a high specificity of 79% and 91%, respectively. Conclusions: Almost one in four patients with EOA < 1 cm2 had non-severe AS according to guideline-recommended multiparametric assessment. Direct valve planimetry revealed poor diagnostic accuracy and should be interpreted with caution. Usual prognostic cut-off values for DI > 0.24 and ELI > 0.6 cm2/m2 identified non-severe AS with high specificity and should therefore be included in the assessment of low-gradient AS.

Funder

Edwards Lifesciences

Publisher

MDPI AG

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