We aimed to compare concordant high gradient (HG) aortic stenosis (AS) (aortic valve area [AVA]<1cm² and mean pressure gradient [MPG]≥40mmHg) and discordant HG-AS patients (AVA≥1cm² and MPG≥40mmHg) in terms of management and 5-year survival.

Despite the lack of evidences, European guidelines have suggested that discordant HG-AS should be considered as severe AS.

We included 2701 patients (mean age 76 years) with HG-AS (2606 concordant and 95 discordant) and preserved ejection fraction (EF).

After adjustment, patients with discordant HG-AS experienced lower 5-year survival than those with concordant HG-AS [HR (95%CI)=1.59(1.04–2.56)]. The one and five-year cumulative incidence of aortic valve replacement (AVR) was lower for discordant HG-AS (61±5% and 83±4% versus 82±1% and 90±1% for concordant HG-AS, P<0.001) with a longer delay to AVR (26±23 months for discordant vs. 13±15 months for concordant HG-AS). After further adjustment for AVR, both groups had comparable outcomes (P=0.94) and AVR was associated with a marked reduction in mortality in patients with discordant HG-AS [HR (95%CI)=0.15(0.06–0.36)]. After propensity matching for age, body surface area, symptoms, comorbidities and MPG, estimated five-year survival rates were still lower for patients with discordant HG-AS than for concordant HG-AS (78±5% vs. 91±3%; P=0.009), while AVR (77.8% vs. 88.9%; P=0.035) and early AVR (50.0% vs. 63.3%; P=0.049) were less frequently performed in discordant than in concordant HG-AS (Fig. 1).

In clinical practice, patients with discordant HG-AS are less referred for AVR and later than those with concordant HG-AS resulting in excess mortality. Consequently, after exclusion of a reversible high flow status, discordant HG-AS should be considered as severe AS and managed as such. Concordant versus discordant high-gradient AS.