Impact of the invasively measured flow-gradient pattern on clinical outcomes and ventricular remodeling after transcatheter aortic valve implantation in patients with severe aortic stenosis and preserved ejection fraction.

To investigate clinical outcomes and cardiac remodeling according to cardiac magnetic resonance (CMR) of the invasively measured different flow/gradient entities of severe aortic stenosis (AS) with preserved left ventricular ejection fraction (EF) after transcatheter aortic valve implantation (TAVI). All consecutive patients with preserved EF and severe AS undergoing right heart catheterization and treated with TAVI between 2007 and 2017 were split into four groups: normal-flow high-gradient (NF-HG n = 113, 25.9%); low-flow high-gradient (LF-HG n = 190, 43.6%); normal-flow low-gradient (NF-LG n = 50, 11.5%); and low-flow low-gradient (LF-LG n = 83, 19%). Patients with LF were older (81.9 ± 6 vs. 80.1 ± 6, p = 0.004); had a higher rate of atrial fibrillation (45.8% vs. 27.6%, p < 0.001); and had a higher EuroScore (p = 0.002). Significant improvement of functional status was noted in all four subgroups. However, the benefit at 30 days was more pronounced in HG patients. In CMR, at 6 months, we observed a significant regression of LV mass in NF-HG, LF-HG, and LF-LG but not in NF-LG patients. Patients with HG AS showed a lower rate of all-cause mortality at 5 years follow-up compared to LG AS (42.3% vs. 58%; p = 0.024). No difference in long-term mortality was observed between LF and NF AS (43.6% vs. 50%, p = 0.87). In patients with severe AS and preserved EF, patients with all invasively measured flow-gradient entities improved functionally after TAVI. High-gradient AS-regardless of the flow status-showed the most pronounced LV mass regression at 6-month CMR follow-up, had the best clinical improvement, and the lowest 5-year all-cause mortality after TAVI.