Importance of concomitant functional mitral regurgitation on survival in severe aortic stenosis patients undergoing aortic valve replacement

BACKGROUND Mitral regurgitation(MR)is commonly seen in patients with severe aortic stenosis(AS)undergoing aortic valve replacement(AVR).But the long-term implications of MR in AS are unknown.AIM To investigate MR’s impact on survival of patients undergoing surgical AVR for severe AS.METHODS Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003,287 underwent AVR forming the study cohort.They were followed up to death or till the end of 2019.Chart reviews were performed for clinical,echocardiographic,and therapeutic data.MR was graded on a 1-4 scale.Mortality data was obtained from chart review and the Social Security Death Index.Survival was analyzed as a function of degree of MR.RESULTS The mean age of the severe AS patients who had AVR(n=287)was 72±13 years,46%women.Over up to 26 years of follow up,there were 201(70%)deaths,giving deep insights into the determinants of survival of severe AS who had AVR.The 5,10 and 20 years survival rates were 75%,45%and 25%respectively.Presence of MR was associated with higher mortality in a graded fashion(P=0.0003).MR was significantly associated with lower left ventricular(LV)ejection fraction and larger LV size.Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size.By Cox regression,MR,lower ejection fraction(EF)and larger LV end-systolic dimension were independent predictors of higher mortality(χ^(2)=33.2).CONCLUSION Presence of greater than 2+MR in patients with severe AS is independently associated with reduced survival in surgically managed patients,an effect incremental to reduced EF and larger LV size.We suggest that aortic valve intervention should be considered in severe AS patients when>2+MR occurs irrespective of EF or symptoms.

Evaluation of Patients with Severe Aortic Stenosis after TAVI with Self-Expandable vs. Balloon-Expandable Devices

Background: The introduction of transcatheter aortic valve implantation (TAVI) for the treatment of severe aortic stenosis (SAS) has expanded the therapeutic possibilities for successfully managing SAS in cases with intermediate and high surgical risks. However, the complications and outcomes of new devices have not been studied enough. Hence, the purpose of this study is to evaluate the midterm results of the Core Valve and Evolute R self-expandable (SE) devices versus the Edwards SAPIEN balloon-expandable (BE) devices. Methods and Material: This was a quasi-experimental study conducted in Tehran, Iran, from May 2012 to June 2017. SAS patients who were not ideal candidates for surgery were randomly assigned to either SE or BE groups. For each patient, a questionnaire, including four sections comprised of Basic characteristics, echocardiographic, angiographic, and Computed Tomography (CT) scan data was filled. TAVI was followed by echocardiography a week later and after three months they were reevaluated by another questionnaire. Results: The total number of patients was 60. The mean ages of patients undergoing the procedure with SE or BE devices were 81.2 ± 8 and 79.8 ± 7, respectively. Mortality occurred in 20% of the patients (5 cases in the SE group and 7 cases in the BE);mortality causes were 66.6 % cardiac and 33% non-cardiac. Moderate to severe Paravalvular leakage in both groups did not differ significantly. The mortality rate was 5 (41.6%) in the SE group versus 7 (58.3%) in the BE group (P > 0.05). Conclusion: In conclusion, the BE group did not experience fewer paravalvular leaks in comparison with the SE. Morbidity and mortality between the BE and the SE groups did not differ significantly.

Medical management of symptomatic severe aortic stenosis in patients non-eligible for transcatheter aortic valve implantation

1 Transcatheter aortic valve implantation in symptomatic severe aortic stenosis: where do we stand? Aortic stenosis occurs in 2%-9% of patients over the age of 65, the most common cause being degenerative.^([1,2]) The preferred treatment in symptomatic severe aortic stenosis(SAS) is surgical aortic valve replacement(SAVR), but in the elderly, the surgical risk can be greater than the benefit.([3]).

Measuring frailty in patients with severe aortic stenosis:a comparison of the edmonton frail scale with modified fried frailty assessment in patients undergoing transcatheter aortic valve replacement

Frailty is generally defined as a clinical syndrome of decreased physiologic reserve which drives to increased vulnerability and susceptibility to different stressors together with poor recovery to homeostasis.[1]The relevance of frailty status in a wide range of prospective cohorts is mostly related to an increasing burden in both mortality,hospital readmissions,disability,and falls.

A meta-analysis of 1-year outcomes of transcatheter versus surgical aortic valve replacement in low-risk patients with severe aortic stenosis

Background Transcatheter aortic valve replacement(TAVR)for the treatment symptomatic severe aortic stenosis(AS)is indicated in patients with intermediate or higher surgical risk.Latest trials showed TAVR,and surgical aortic valve replacement(SAVR)perform similarly at 1-year for the composite outcomes of mortality,stroke and rehospitalization.We performed a comprehensive meta-analysis to compare individual outcomes at 1-year for TAVR compared to SAVR in low-risk patients.Methods Pub Med,Embase,and Cochrane central were searched for all the randomized controlled trials(RCTs)that reported 1-year comparative outcomes of TAVR and surgical aortic valve replacement(SAVR).Our conclusions are based upon the random-effects model using Der Simonian-Laird estimator.Results Data from 4 trials and 2887 randomized patients showed that TAVR had lower rates of all-cause mortality,cardiovascular mortality,and atrial fibrillation compared to SAVR at 1-year follow-up(P<0.05 for all).Also,TAVR was also associated with a significantly higher risk of permanent pacemaker implantation and moderate-severe paravalvular leak(P<0.05).Conclusions The latest randomised trial data demonstrates that in short-term,TAVR is safe and effective in reducing all-cause mortality or stroke.Longer follow-up of RCTs is needed to determine the durability of clinical benefits in TAVR over SAVR in low-risk patients.

New Insight in the Assessment of Left Ventricular Function in Paradoxical Low Flow Aortic Stenosis Patients with Normal Left Ventricular Ejection Fraction: A Mini-Review

Paradoxical valvular aortic stenosis (VAS) is a challenging area of clinical cardiology for the practitioners. It involves a small aortic valve area, low flow rate and mean pressure gradient although there is normal left ventricular ejection fraction. The aim of this study was to assess left ventricular (LV) dysfunction in a symptomatic severe aortic valve stenosis which is of crucial importance in identifying patients at risk of heart failure, postoperative complications and increased mortality. There are new insights which are involved in assessment of LV myocardial function including global longitudinal strain (GLS) by two-dimensional speckle tracking echocardiography (2D STE), myocardial performance index (MPI) and maximum rate of LV pressure rise (+dP/dt) during isovolumetric contraction time of the LV. This information can provide both diagnostic and prognostic information in addition to standard echocardiographic and clinical parameters. However, a profound understanding of the complex interaction between loading conditions, chamber geometry and contractility is necessary for the correct interpretation of myocardial deformation in order to draw appropriate conclusions in patients with aortic valve disease. This mini review is related to new and novel insights into the assessment of left ventricular function (LVF) in paradoxical low flow aortic stenosis patients with normal left ventricular ejection fraction (LVEF).

The Prognostic Value of Myocardial Deformation in Patients with Congenital Aortic Stenosis

Aims:To assess the prognostic value of left ventricular(LV)global longitudinal strain(GLS)and global longitudinal early diastolic strain rate(GLSre)with regard to cardiovascular events,as congenital aortic stenosis(AoS)is associated with significant mortality and morbidity but predictors for clinical outcome are scarce.Strain analysis provides a robust and reproducible method for early detection of LV dysfunction,which might be of prognostic value.Methods:This prospective study,included clinically stable patients with congenital AoS between 2011–2013.LV GLS and GLSre was performed in the apical 4,3 and 2-chamber views using Tomtec software.The endpoint was a composite of death,heart failure,hospitalization,arrhythmia,thrombo-embolic events and re-intervention.Results:In total 138 patients were included(33[26–43]years,86(62%)male),NYHA class I:134(97%).Mean LV GLS was–15.3±3.2%,GLSre 0.66±0.18 s–1.Both correlated with NT-proBNP,LV volumes and ejection fraction(strongest LV GLS with LV EF:r–0.539,p<0.001,strongest LV GLSre with age:r–0.376,p<0.001).During median follow-up of 5.9[5.5–6.2]years,the endpoint occurred in 53(38%)patients:4 patients died,9 developed heart failure,22 arrhythmias,8 thrombo-embolic events and 35 re-interventions.Both LV GLS(standardized HR(sHR 0.62(95%CI 0.47–0.81)and GLSre(sHR 0.62(95%CI 0.47–0.83)were associated with the endpoint.Additional multivariable analysis showed that both GLS and GLSre were associated independent of left atrial volume,NT-proBNP and prior re-interventions.Conclusion:Left ventricular GLS and GLSre are reduced in adult patients with congenital AoS.Both markers are associated with adverse cardiac events and have clear clinical relevance.

Aortic stenosis and Heyde’s syndrome:A comprehensive review

Heyde’s syndrome is an under reported systemic disease of gastrointestinal and cardiac manifestation in older adults.It is characterized by a triad of aortic stenosis,angiodysplasia with bleeding and acquired von Willebrand syndrome.It is characterized by proteolysis of high molecular weight multimers of von Willebrand Factor and loss of platelet mediated homeostasis.Heyde’s syndrome is a treatable condition in most cases,especially in the current era of evolution in interventional cardiology and gastroenterology.There are currently no established guidelines in the management of this condition due to paucity of high quality studies,which warrant future trials.High index of suspicion and increasing the awareness of the syndrome among the general practitioners and sub-specialists will improve the diagnostic potential of Heyde’s syndrome.Future studies may change the management aspect of Heyde's syndrome and pave a path for drawing specific guidelines and algorithms.The aim of our review article is to summarize the basic pathophysiology,diagnostics and management of Heyde’s syndrome with a special attention to Transcatheter aortic valve replacement.

Rapid right ventricular pacing for balloon valvuloplasty in congenital aortic stenosis:A systematic review

BACKGROUND Balloon aortic valvuloplasty(BAV)is a well-established treatment modality for congenital aortic valve stenosis.AIM To evaluate the role of rapid right ventricular pacing(RRVP)in balloon stabilization during BAV on aortic regurgitation(AR)in pediatric patients.METHODS A systematic review of the MEDLINE,Cochrane Library,and Scopus databases was conducted according to the PRISMA guidelines(end-of-search date:July 8,2020).The National Heart,Lung,and Blood Institute and Newcastle-Ottawa scales was utilized for quality assessment.RESULTS Five studies reporting on 72 patients were included.The studies investigated the use of RRVP-assisted BAV in infants(>1 mo)and older children,but not in neonates.Ten(13.9%)patients had a history of some type of aortic valve surgical or catheterization procedure.Before BAV,58(84.0%),7(10.1%),4(5.9%)patients had AR grade 0(none),1(trivial),2(mild),respectively.After BAV,34(49.3%),6(8.7%),26(37.7%),3(4.3%),patients had AR grade 0,1,2,and 3(moderate),respectively.No patient developed severe AR after RRVP.One(1.4%)developed ventricular fibrillation and was defibrillated successfully.No additional arrhythmias or complications occurred during RRVP.CONCLUSION RRVP can be safely used to achieve balloon stability during pediatric BAV,which could potentially decrease AR rates.

Single-Stage Repair of a Critical Aortic Coarctation, a Bicuspid Aortic Stenosis and an Ascending Aortic Aneurysm

We report a 26-year-old man with critical aortic coarctation, severe bicuspid aortic valve stenosis, infective endocarditis and ascending aortic aneurysm. He underwent simultaneously in singlestage a Bentall’s procedure and an extra-anatomic ascending-descending aortic bypass grafting by 14-mm Dacron tube, through median sternotomy. The immediate postoperative outcome was favourable. The CT scan control for 7 years after surgery showed a good patency of the extra-anatomic bypass.

Aortic Stenosis and Stressed Heart Morphology

Myocardial geometric remodeling is a response to increased stress which includes increased afterload situations during clinical conditions. In this review, we have focused on early and late geometric features in aortic stenosis, importance of recognition of these findings and consequences due to progression of valve disease. We have also pointed out the similarities in early focal and global myocardial geometric remodeling in acute and chronic conditions as hypertension and acute stress cardiomypathy which are associated with myocardial functional and geometric response to acute or chronic stress exposure and relevant increased afterload. In aortic stenosis, target organ involvement in disease progression has been evaluated and discussed in the report. In addition to quantitative evaluation of valve disease, importance of myocardial involvement and global assessment of patients with aortic stenosis also have been mentioned in the report. Finally, we have discussed the importance of global myocardial geometric changes and timing for surgery before development of heart failure in this specific group of patients.

The effects of severe aortic stenosis and high pulmonary artery pressure on aortic valve replacement

Background: Pulmonary hypertension development in pure severe aortic stenosis is a situation that affects mortality and morbidity. Material and Methods: Data from files of 31 patients with systolic pulmonary artery pressure over 50 mm Hg and with pure severe aortic stenosis, and underwent aortic valve replacement in our clinic were examined retrospectively. Results: Preoperative effort capacities of the patients were evaluated as follows according to NYHA;4 patients class 1-2, 16 patients class 3, and 11 patients class 4. Twenty-five metal, and 6 biologic aortic valves were used. Postoperative hospital mortality was recorded as 12% with 4 patients. Patients were reevaluated on the postoperative 2nd and 12th months. Pulmonary arterial pressure of the patients was measured using echocardiography. Preoperative average pulmonary artery systolic pressure was measured as 55 ± 3 mmHg. The average pressure was measured as 41 ± 3 mmHg on the 2nd, and as 37.8 ± 4 mmHg on the 12th month. The effort capacity evaluation in the postoperative 2nd month was as follows: 11 patients class 1-2, 12 patients class 3, and 4 patients class 4. The effort capacity evaluation conducted in the 12th month was: 14 patients were class 1-2, 10 patients were class 3, and 2 patients were class 4. During the follow-up 1 year, survival rate of the patients was determined as 83.8% average, 5 year survival rate was determined as 61.5%. Conclusion: We believe that AVR may be performed in severe aortic stenosis cases with high pulmonary pressure with acceptable ortality, leading to a better quality and longer life.

Paradoxical Low Flow Low Gradient Severe Aortic Stenosis—An Under-Recognized Entity

Some patients with severe aortic stenosis (AS), due to restrictive cardiac physiology, paradoxically have relatively low flow and low gradients across stenotic aortic valves despite preserved left ventricular (LV) systolic function. It results in symptoms and reduced quality of life and carries a high mortality. Whilst this form of severe AS, termed paradoxical low flow low gradient (pLFLG), is well reported, patients with this diagnosis experience inappropriate barriers to aortic valve replacement (AVR), the only efficacious treatment. We present the case of an 88-year-old female with 12 months of exertional dyspnoea on a background of hypothyroidism and hypercholesterolemia. Transthoracic echocardiogram (TTE) revealed LV hypertrophy, with a small LV cavity size and reduced stroke volume, yet normal systolic function. A heavily calcified aortic valve was identified with severe aortic stenosis, based on valve area, yet with incongruous mean transvalvular gradient of 25 mmHg (severe ≥ 50 mmHg). Following exclusion of other differential diagnoses, her symptoms were attributed to paradoxical LFLG severe AS. She was however declined definitive transcatheter aortic valve implantation (TAVI) due to her paradoxically low mean aortic gradient. Following further deterioration in her symptoms and supportive quantification of poor exercise performance, she was ultimately re-referred, accepted, and underwent TAVI. Following her AVR, the patient experiences significant improvement in both symptoms and quality of life after only one month. Paradoxical LFLG severe AS remains a well-documented yet under recognized disease. It carries high morbidity and mortality if untreated, yet is significantly less likely to be referred and accepted for intervention. With its prevalence expected to rise with an ageing population, this case serves as a timely reminder for clinicians to address the under recognition of important pathology.

Emergency Treatment of Acute Decompensated Severe Aortic Stenosis with Transcatheter Aortic Valve implantation under the Coplane View Using J-Tipped Wires Fluoroscopy

Patients experiencing severe aortic stenosis with acute decompensation often face elevated surgical aortic valve replacement risks,leading to high postoperative mortality rates.However,for some patients eligible for transcatheter aortic valve implantation(TAVI),computed tomography angiography for assessing the aortic root and coronary artery might be challenging before the TAVI procedure.This case highlights a patient who underwent emergency TAVI guided by coplane view generated using J-tipped wires fluoroscopy without computed tomography evaluation before the TAVl.This approach reduces contrast usage during the TAVI procedure,significantly mitigating the risks of renal injury and heart function deterioration.

Emergency Hybrid Correction in a Newborn with Critical Aortic Valve Stenosis with Acute Pulmonary Edema in the First Hour after Birth

Critical aortic valve stenosis in newborns is the cause of a severe clinical condition with the onset of symptoms during first hours after birth.We present a clinical case of a successful surgical correction of a critical aortic stenosis using a hybrid method applied in a newborn during the first day of life.The infant was diagnosed with a hypoplastic left heart complex with an intact atrial septum(aortic and mitral valves stenosis variant),that led to the cardiogenic shock and acute pulmonary edema.The procedure included bilateral banding of the pulmonary artery branches and atrioseptostomy with stenting of the interatrial septum.The surgery was performed through a median sternotomy.

Animal Model of Aortic Valve Calcification: Their Methodology Helps Us Understand Aortic Valve Calcification

Aortic valve calcification disease (CAVD) is the most prevalent degenerative valve disease in humans, leading to significant morbidity and mortality. Despite its common occurrence, our understanding of the underlying mechanisms remains incomplete, and available treatment options are limited and risky. A more comprehensive understanding of the biology of CAVD is essential to identify new therapeutic strategies. Animal models have played a crucial role in advancing our knowledge of CAVD and exploring potential treatments. However, these models have inherent limitations as they cannot fully replicate the complex physiological mechanisms of human CAVD. In this review, we examine various CAVD models ranging from pigs to mice, highlighting the unique characteristics of each model to enhance our understanding of CAVD. While these models offer valuable insights, they also have limitations and shortcomings. We propose that the guide wire model shows promise for future CAVD research, and streamlining the methodology could enhance our understanding and expand the research scope in this field.

Transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis： a meta analysis

Background Transcatheter aortic valve implantation （TAVI） has emerged as the treatment choice for non-operable patients with severe symptomatic aortic stenosis （AS） and may be a good alternative to surgery for those at very high or prohibitive surgical risk. We performed a meta-analysis to evaluate the comparative benefits of TAVI versus surgical aortic valve replacement （SAVR） in patients with severe AS. Methods A comprehensive literature search of PubMed, Embase, ScienceDirect and Cochrane Central Register of Codtrolled trials was performed, and randomized trials as well as cohort studies with propensity score analysis were included. Results One randomized trial （n=699） and six retrospective cohort studies （n=781） were selected for meta-analysis. Mortality at 30-day and 1-year follow-up was comparable between TAVI and SAVR. Despite similar incidences of stroke, myocardial infarction, re-operation for bleeding, and renal failure requiring dialysis, TAVI was associated with a lower occurrence rate of new-onset atrial fibrillation （OR 0.51,95% CI 0.33-0.78） and shorter procedural time （mean difference -67.50 minutes, 95% CI -87.20 to -47.81 minutes）. Post-operative aortic regurgitation and permanent pacemaker implantation were more common in patients after TAVI than in those with SAVR （OR 5.53, 95% CI 3.41-8.97; OR 1.71, 95% CI 1.02-2.84, respectively）. Conclusion In patients with severe symptomatic AS, TAVI and SAVR did not differ with respect to short- and mid-term survival, but the incidence of permanent pacemaker implantation and post-procedural aortic regurgitation remain relatively high after TAVI.

Incidence of coronary artery disease before valvular surgery in isolated severe aortic stenosis

Background Angina pectoris has been recognized as one of the principal symptoms of aortic valve stenosis （AS）,even in patients without significant coronary artery disease （CAD）.However,the incidence of angina pectoris and related CAD in such patients is controversial.There is continuing debate as to whether coronary angiography is necessary before aortic valve replacement （AVR） in patients with severe AS.The purpose of this study was to evaluate the incidence and predictors of CAD in patients with severe AS in a Korean population.Methods Data from all consecutive patients with severe AS undergoing AVR at a major tertiary cardiac and vascular center in Korea were entered in a prospective registry beginning in 1995.Clinical and echocardiographic follow-up data were recorded into the database annually.Significant CAD was defined as one or more major coronary arteries having an estimated narrowing of ≥70％ and left main coronary arteries having an estimated narrowing of ≥50％ on coronary angiography.We excluded patients with multiple valve disease,significant aortic regurgitation,or prior CAD or valve surgery.Results Totally 574 patients with severe AS （mean age,（65.9±9.6） years） were enrolled in this study.Significant CAD was found in 61 patients （10.6％）.Factors associated with increased likelihood of CAD were age,hypertension,diabetes mellitus,chronic renal failure,carotid disease,and aorta calcification.In Logistic regression analysis,the independent predictor of the presence of CAD was age （P=0.011）.The incidence of CAD increased significantly at 69.2 years of age.Having two risk factors for cardiovascular disease was the most useful cutoff to predict whether a patient was going to have significant CAD.Conclusions There was a low incidence of significant CAD in a population of Korean patients with severe AS.Therefore,coronary angiography before AVR will be considered in patients with multiple risk factors for cardiovascular disease or in patients more than 69 years of age without risk factors for cardiovascular disease.

Anatomical morphology of the aortic valve in Chinese aortic stenosis patients and clinical results after downsize strategy of transcatheter aortic valve replacement

Background:The study aimed to describe the aortic valve morphology in Chinese patients underwent transcatheter aortic valve replacement(TAVR)for symptomatic severe aortic stenosis(AS),and the impact of sizing strategies and related procedural outcomes.Methods:Patients with severe AS who underwent TAVR were consecutively enrolled from 2012 to 2019.The anatomy and morphology of the aortic root were assessed."Downsize"strategy was preformed when patients had complex morphology.The clinical outcomes of patients who performed downsize strategy were compared with those received annular sizing strategy.The primary outcome was device success rate,and secondary outcomes included Valve Academic Research Consortium-3 clinical outcomes variables based on 1-year follow-up.Results:A total of 293 patients were enrolled.Among them,95 patients(32.4%)had bicuspid aortic valve.The calcium volume(Hounsfield Unit-850)of aortic root was 449.90(243.15-782.15)mm3.Calcium is distributed mostly on the leaflet level.Downsize strategy was performed in 204 patients(69.6%).Compared with the patients who performed annular sizing strategy,those received downsize strategy achieved a similar device success rate(82.0%[73]vs.83.3%[170],P=0.79).Aortic valve gradients(downsize strategy group vs.annular sizing group,11.28 mmHg vs.11.88 mmHg,P=0.64)and percentages of patients with moderate or severe paravalvular regurgitation 2.0%(4/204)vs.4.5%(4/89),P=0.21were similar in the two groups at 30 days after TAVR.These echocardiographic results were sustainable for one year.Conclusions:Chinese TAVR patients have more prevalent bicuspid morphology and large calcium volume of aortic root.Calcium is distributed mostly on the leaflet level.Compare with annular sizing strategy,downsize strategy provided a non-inferior device success rate and transcatheter heart valve hemodynamic performance in self-expanding TAVR procedure.

What is the real practice of exercise echocardiographic testing in asymptomatic patients with severe aortic stenosis？

Background Although exercise testing has been suggested to help predict clinical outcome, limited data are available to guide how exercise Doppler echocardiography （ECG） can be used clinically in asymptomatic patients with aortic stenosis （AS）. The aim of this study was to assess the clinical value of exercise echocardiographic testing in asymptomatic patients with severe AS. Methods Symptom-limited treadmill exercise testing using the modified Bruce protocol was performed in 31 asymptomatic patients （mean age （62＋11） years） with severe AS （aortic valve area 〈1 cm2, peak aortic velocity （AV Vmax） 〉4 m/sec, or a mean transaortic pressure gradient （AV mean PG） 〉40 mmHg （1 mmHg=0.133 kPa）） with normal left ventricular （LV） systolic function （LV ejection fraction （EF） 〉50%）. Clinical symptoms, vital signs, ECG, and Doppler hemodynamics were obtained during and/or immediately after exercise. Results Aortic valve replacement （AVR） was performed in 18 patients during follow-up. The patients who had AVR exhibited higher baseline AV mean PG （51 （35-84） vs. 44 （25.2-57.0） mmHg; P=0.031）. There were no significant differences between the AVR group and non-AVR group including exercise duration （7.47 （2.32-11.59） vs. 7.25 （4.06- 10.52） minutes, P=0.917）, exercise capacity （10.1 （4.6-12.8） vs. 10.1 （7.0-12.8） metabolic equivalents, P=0.675）, and an increment in AV mean PG by exercise （18.5 （3.2-48.0） vs. 12.6 （4.4-32.1） mmHg, P=0.366）. Univariate regression analysis revealed that independent determinant of AVR was the baseline AV mean PG （P=-0.031）. Conclusions Although additional value of exercise ECG was demonstrated, baseline transaortic mean pressure gradient is the major determinant of AVR. Further large-scale prospective studies are required to determine whether surgery should be recommended in the presence of an abnormal exercise ECG in asymptomatic severe AS.