Objective Low-gradient (LG) severe aortic stenosis (AS) and preserved EF with reduced stroke volume are associated with an adverse prognosis, but the relationship of stroke volume index (SVI) with mortality among a range of values is unknown. We investigated the prognostic impact of SVI in this population.

Methods We examined 405 consecutive patients with preserved EF (≥50%) and severe AS (valve area <1.0 cm²) with LG (<40 mm Hg) using echocardiography. Patients were stratified into quartiles based on SVI distribution (group 1: <38 mL/m² (n=90), group 2: 38–43 mL/m² (n=105), group 3: 43–48 mL/m² (n=104) and group 4: >48 mL/m² (n=106)).

Results Groups 1 and 2 had poorer survival with medical management compared with 3 and 4 (3-year estimate 46% and 67% vs. 78% and 73%, respectively, p=0.002) although aortic valve replacement referral rate was similar (53%–62%, p=0.57). An inverse relationship was observed between SVI and mortality (HR 1.28 (1.11 to 1.46) per every 5 mL/m² decrease in SVI). After multivariable analysis, SVI was the strongest predictor of mortality (HR 0.92 (0.89 to 0.95), p<0.0001). Using different SVI cutpoints, SVI <35 was associated with highest mortality (HR 2.36 (1.49 to 3.73), p<0.001), followed by SVI <38 (HR 2.09 (1.39 to 3.16), p<0.001) and by SVI <43 (HR 2.05 (1.38 to 3.05), p<0.001). Survival with SVI ≥43 was similar to age and sex-matched controls (3-year estimate 84%, p=0.24); survival for SVI <43 was significantly worse (3-year estimate 63%, p<0.001).

Conclusions Lower SVI is incrementally associated with mortality in LG severe AS with preserved EF. These findings have implications for classification of AS severity, identification of high-risk groups and subsequent management.