Symptomatic paradoxical low gradient severe aortic stenosis: A possible link to heart failure with preserved ejection fraction.

Background: There is an ongoing debate regarding optimal management of patients with paradoxical low gradient severe aortic stenosis (PLG-SAS). We hypothesized that the presence of symptoms is closely associated with future adverse outcome. We aimed to determine the relation between symptoms and outcome in patients with PLG-SAS.

Methods: We prospectively enrolled 222 patients with PLG-SAS. Left ventricular (LV) volumes, mass, and strain were measured by three-dimensional echocardiography. The primary end-point was cardiac events including cardiac death, ventricular fibrillation, and heart failure leading to hospitalization.

Results: There were 65 cases of symptomatic PLG-SAS and 157 cases of asymptomatic PLG-SAS. Patients with symptomatic PLG-SAS received beta-blockers, angiotensin blockers, and diuretics more frequently and showed higher levels of B-type natriuretic peptide than patients with asymptomatic PLG-SAS. Although LV chamber parameters were not different, patients with symptomatic PLG-SAS had significantly higher E-wave velocity and E/A ratio than patients with asymptomatic PLG-SAS. During the median follow-up of 18 months, 20 patients reached the primary end-point. Patients with symptomatic PLG-SAS had significantly worse prognosis than patients with asymptomatic PLG-SAS. A similar trend was observed while comparing with the propensity-score-matched cohort after adjusting for age, sex, stroke volume index, and severity of AS.

Conclusions: Symptomatic PLG-SAS is associated with poorer prognosis even after adjusting for flow status and severity of AS. Therefore, presence of symptoms is not always related to the severity of AS itself but might be related to the underlying comorbidities. Our results suggest a possible link between PLG-SAS and heart failure with preserved ejection fraction in some symptomatic patients.