How to deal with low-flow low-gradient aortic stenosis and reduced left ventricle ejection fraction: from literature review to tips for clinical practice

Abstract

Low-flow low-gradient aortic stenosis (LFLG AS) with reduced left ventricle ejection fraction (LVEF) is still a diagnostic and therapeutic challenge. The aim of this paper is to review the latest evidences about the assessment of the valvular disease, usually difficult because of the low-flow status, and the therapeutic options. Special emphasis is given to the available diagnostic tools for the characterization of LFLG AS without functional reserve at stress echocardiography and to the factors that clinicians should evaluate to choose between surgical aortic valve repair, transcatheter aortic valve implantation, or medical therapy.

Risk assessment in patients with left ventricular systolic dysfunction following transcatheter aortic valve replacement

“…Accurate risk stratification models and clear therapeutic strategies for these cohorts remain unknown when compared to those with preserved ejection fraction. 4 In addition to moderate or greater tricuspid regurgitation, higher serum C-reactive protein was a significant risk factor of mortality in this study, although it did not reach statistical significance in the multivariate analysis. Similarly, a meta-analysis of 14 studies including 3499 TAVR candidates demonstrated that a baseline higher C-reactive protein level was associated with midterm all-cause mortality.…”

“…However, there is a lack of data investigating risk factors of post‐TAVR mortality in patients with left ventricular systolic dysfunction. Accurate risk stratification models and clear therapeutic strategies for these cohorts remain unknown when compared to those with preserved ejection fraction 4 …”

“…2 However, mortality in patients with left ventricular systolic dysfunction following TAVR remains unsatisfactorily high, 3 with limited proven therapeutic options. 4 Detailed analyses to understand clinical factors associated with post-TAVR mortality are needed to better predict postprocedural risk while ultimately informing acceptable patient selection. In this study, we investigated post-TAVR clinical variables associated with cardiovascular mortality in patients with left ventricular systolic dysfunction.…”

“…Transcatheter aortic valve replacement (TAVR) is an accepted, evidence‐based therapeutic option for high‐surgical risk patients with severe aortic stenosis, 1 with new data suggesting superiority compared to surgical aortic valve replacement in the low surgical risk population 2 . However, mortality in patients with left ventricular systolic dysfunction following TAVR remains unsatisfactorily high, 3 with limited proven therapeutic options 4 . Detailed analyses to understand clinical factors associated with post‐TAVR mortality are needed to better predict postprocedural risk while ultimately informing acceptable patient selection.…”

Early and mid-term outcome of patients with low-flow–low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves

“…TAVR seems to be promising in this setting because of its increasing procedural safety (short operative time and no need for extracorporeal circulation with consequent better myocardial protection), as well as hemodynamic performance of transcatheter devices ( 10 ). However, TAVR downsides remain, such as post-procedural paravalvular leak (PVL) and need for permanent pacemaker (PPM), that might be detrimental in the setting of an already impaired LVEF ( 11 , 12 ). To date, evidence supporting the value of TAVR in this setting is lacking ( 13 – 16 ).…”