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Multimodality imaging in low-flow low-gradient aortic stenosis: impact on severity classification and outcome prediction
Session:
Sessão de Comunicações Orais 12 – Doença Valvular Cardíaca: diagnóstico, estratificação de risco e abordagem terapêutica
Speaker:
Mariana Sá
Congress:
CPC 2026
Topic:
F. Valvular, Myocardial, Pericardial, Pulmonary, Congenital Heart Disease
Theme:
15. Valvular Heart Disease
Subtheme:
15.2 Valvular Heart Disease – Epidemiology, Prognosis, Outcome
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Mariana Raimundo Sá; Ana Rita Pereira; Adriana Silva; Rafael Viana; Paula Fazendas; Tiago Lobão; Lourenço Aguiar; Sofia Alegria; Inês Cruz; Ana Rita Almeida; Isabel João; Hélder Pereira
Abstract
<p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong>Background:</strong> Differentiating true severe from pseudo-severe low-flow low-gradient (LFLG) aortic stenosis (AS) remains challenging with echocardiography alone. The 2025 ESC Guidelines highlight CT-derived aortic valve calcium (AVC) scoring as an alternative to dobutamine stress echocardiography (DSE) including in patients with reduced left ventricular ejection fraction (LVEF).</span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong>Aim:</strong> To evaluate how CT-AVC scoring, alone or combined with DSE, influences diagnostic classification and clinical outcomes in LFLG AS.</span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong>Methods:</strong> A retrospective study was conducted by reviewing all transthoracic echocardiograms performed between 2020–2023 at a tertiary centre. Patients with LFLG AS who underwent non-contrast CT AVC scoring and/or DSE were selected and divided into four groups: CT-only, DSE-only, concordant CT+DSE, and discordant CT+DSE. Classification as true severe AS followed guideline criteria. The primary endpoint was all-cause mortality at 1-year; the secondary was aortic valve replacement (AVR) at 1-year.</span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong>Results:</strong> From 139 patients with LFLG AS, 44 (31.7%) met inclusion: mean age 76.0<span style="font-family:Symbol">±</span>7.5 years; 75% male and 75% with LVEF<50%. Baseline echocardiographic parameters were peak mean velocity 3.5<span style="font-family:Symbol">±</span>0.2 m/s; mean gradient 26.5<span style="font-family:Symbol">±</span>7.5 mmHg; mean aortic valvular area (AVA) 0.8<span style="font-family:Symbol">±</span>0.1 cm2. Using either modality, 31 patients (70.5%) were classified as true severe AS, more often by CT (89.3%) than DSE (48.0%). Patients were divided into predefined groups: CT-only (n=19), DSE-only (n=16), concordant CT+DSE (n=4), and discordant CT+DSE (n=5). Agreement between CT AVC score and DSE was poor (55.6%, κ=–0.200) and no significant association was found between the modalities (χ²=0.563, p=0.453). At 1-year follow-up, survival differed among groups (log-rank p=0.031, event rate 0% CT-only, 37.5% DSE-only, 50% concordant, 40% discordant). Overall 1-year AVR was 50% and differed across groups (p=0.042), highest in concordant severe cases (100% vs 20% discordant, 18.8% DSE-only, 15.8% CT-only).</span></span></span></p> <p style="text-align:justify"><span style="font-size:medium"><span style="font-family:Aptos,sans-serif"><span style="color:#000000"><strong>Conclusion:</strong> Fewer than one third of patients with echocardiographic features of LFLG AS underwent further diagnostic evaluation. CT-derived AVC scoring more frequently classified cases as true severe LFLG AS, presenting a poor concordance with DSE but the lowest 1-year AVR rate and the most favourable 1-year outcome. Further studies are required to validate these findings and to better define the real diagnostic and prognostic value of AVC scoring in this very challenging patient cohort.</span></span></span></p>
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