Low-Gradient Aortic Stenosis

Monin, Jean‐Luc; Quéré, Jean Paul; Monchi, Mehran; Petit, H.; Baleynaud, Serge; Chauvel, Christophe; Pop, C; Ohlmann, Patrick; Lelguen, C; Dehant, P.; Tribouilloy, Christophe; Guéret, Pascal

doi:10.1161/01.cir.0000079171.43055.46

Cited by 530 publications

(79 citation statements)

References 28 publications

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“…Dobutamine stress echocardiography was not performed on a regular basis. Thus, we were not able to estimate contractile reserve, which is known to affect the outcome of patients with cLF‐LG 31. Only little is known about the role of dobutamine stress echocardiography in pLF‐LG 33.…”

Section: Discussionmentioning

confidence: 95%

“…The reasons for LF are multifactorial, including impaired myocardial contractility, restrictive physiological features, and afterload mismatch with high valvuloarterial impedance 1. Nonrandomized data propose that regardless of the origin, patients with LF have worse outcomes both with and without surgery but may still have an advantage from valve replacement compared with optimal medical therapy 17, 30, 31…”

Section: Discussionmentioning

confidence: 99%

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Predictors of Mortality and Symptomatic Outcome of Patients With Low‐Flow Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

Stachel

Woitek

Haußig

et al. 2018

JAHA

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BackgroundImpaired left ventricular (LV) ejection fraction is a common finding in patients with aortic stenosis and serves as a predictor of morbidity and mortality after transcatheter aortic valve replacement. However, conflicting data on the most accurate measure for LV function exist. We wanted to examine the impact of LV ejection fraction, mean pressure gradient, and stroke volume index on the outcome of patients treated by transcatheter aortic valve replacement.Methods and ResultsPatients treated by transcatheter aortic valve replacement were primarily separated into normal flow (NF; stroke volume index >35 mL/m2) and low flow (LF; stroke volume index ≤35 mL/m2). Afterwards, patients were divided into 5 groups: “NF–high gradient,” “NF–low gradient” (NF‐LG), “LF–high gradient,” “paradoxical LF‐LG,” and “classic LF‐LG.” The 3‐year mortality was the primary end point. Of 1600 patients, 789 (49.3%) were diagnosed as having LF, which was characterized by a higher 30‐day (P=0.041) and 3‐year (P<0.001) mortality. LF was an independent predictor of all‐cause (hazard ratio, 1.29; 95% confidence interval, 1.03–1.62; P=0.03) and cardiovascular (hazard ratio, 1.37; 95% confidence interval, 1.06–1.77; P=0.016) mortality. Neither mean pressure gradient nor LV ejection fraction was an independent predictor of mortality. Patients with paradoxical LF‐LG (35.0%), classic LF‐LG (35.1%) and LF–high gradient (38.1%) had higher all‐cause mortality at 3 years compared with NF–high gradient (24.8%) and NF‐LG (27.9%) (P=0.001). However, surviving patients showed a similar improvement in symptoms regardless of aortic stenosis entity.Conclusions LF is a common finding within the aortic stenosis population and, in contrast to LV ejection fraction or mean pressure gradient, an independent predictor of all‐cause and cardiovascular mortality. Despite increased long‐term mortality, high procedural success and excellent functional improvement support transcatheter aortic valve replacement in patients with LF severe aortic stenosis.

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Section: Discussionmentioning

confidence: 95%

Section: Discussionmentioning

confidence: 99%

Predictors of Mortality and Symptomatic Outcome of Patients With Low‐Flow Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

Stachel

Woitek

Haußig

et al. 2018

JAHA

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“…Low-dose DSE plays an important role in differentiating pseudo- from true severe AS (Fig. 2) [22]. If contractile reserve is present with stress testing (>20% increase in stroke volume), patients with true severe AS may increase their mean AV gradient to >40 mm Hg while maintaining an AVA <1.0 cm 2 .…”

Section: Aortic Valvementioning

confidence: 99%

“…In contrast, the AVA will increase to >1.0-1.2 cm 2 with only a minimal increase in AV gradients in patients with pseudo-severe AS [23]. The presence of contractile reserve has additional prognostic value for patients undergoing AVR being associated with a 5% perioperative morality if present compared to 32% if absent [22]. …”

Section: Aortic Valvementioning

confidence: 99%

The Role of Stress Echocardiography in Valvular Heart Disease: A Current Appraisal

et al. 2017

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Stress echocardiography is a widely available, safe, low-cost, versatile imaging modality which is becoming increasingly recognized as a valuable tool in the assessment of patients with native and prosthetic left-sided valvular heart disease. It provides a quantitative assessment to help guide clinical decision-making when discordance exists between symptoms and severity of valve disease. Exercise (treadmill or bicycle) remains the preferred stress modality, but pharmacological augmentation with dobutamine can be used if needed. Low-dose dobutamine stress echocardiography is specifically valuable in patients with low-flow, low-gradient aortic stenosis when attempting to differentiate true severe aortic stenosis from pseudo-severe aortic stenosis. Stress echocardiography not only identifies high-risk features that indicate need for earlier surgery, it also provides useful information for the peri- and postoperative period, including long-term outcome, risk stratification to guide monitoring frequency, and offers guidance for eligibility in competitive sports participation. As research continues to expand the utility of stress echocardiography in the management of patients with valvular heart disease, future research should focus on the recognition of newer parameters identifying high-risk features including subsequent validation in a large population.

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“…Patients with low‐flow, low‐gradient aortic stenosis (LF‐LG AS) and reduced left ventricular ejection fraction (LVEF) have a poor prognosis with conservative therapy and a high operative mortality with aortic valve replacement (AVR) 1, 2, 3, 4, 5, 6, 7. Risk stratification is essential in these patients to optimize therapeutic management and improve outcomes.…”

Section: Introductionmentioning

confidence: 99%

Relationship Between QT Interval and Outcome in Low‐Flow Low‐Gradient Aortic Stenosis With Low Left Ventricular Ejection Fraction

Dahou

Toubal

Clavel

et al. 2016

JAHA

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Background QT interval has been shown to be associated with cardiovascular events. There is no data regarding the association between QT interval and left ventricular (LV) function and prognosis in patients with low LV ejection fraction (LVEF), low‐flow, low‐gradient aortic stenosis (LF‐LG AS). We aimed to examine the relationship between corrected QT interval (QT c) and LV function and outcome in these patients.Methods and ResultsNinety‐three patients (73±10 years; 74% men) with LF‐LG AS (mean gradient <40 mm Hg and indexed aortic valve area ≤0.6 cm2/m2) and reduced LVEF (≤40%) were prospectively included in this analysis and 63 of them underwent aortic valve replacement within 3 months following inclusion. Prolonged QT c was defined as QT c >450 ms in men and >470 ms in women. LV global longitudinal strain was measured by speckle tracking and expressed in absolute value |%|. QT c correlated with the following: global longitudinal strain (r=−0.40, P=0.005), LVEF (r=−0.27, P=0.02), stroke volume (r=−0.35, P=0.007), and B‐type natriuretic peptide (r=0.45, P=0.0006). During a median follow‐up of 2.0 years, 49 patients died. Prolonged QT c was associated with a 2‐fold increase in all‐cause mortality (hazard ratio=2.05; P=0.01) and cardiovascular mortality (hazard ratio=1.89; P=0.04). In multivariable analysis adjusted for EuroSCORE, aortic valve replacement, previous myocardial infarction, LVEF, and ß‐blocker medication, prolonged QT c was independently associated with all‐cause mortality (hazard ratio=2.56; P=0.008) and cardiovascular mortality (hazard ratio=2.50; P=0.02).ConclusionsIn patients with LF‐LG AS and reduced LVEF, longer QT c interval was associated with worse LV function and increased risk of death. Assessment of QT c may provide a simple and inexpensive tool to enhance risk stratification in LF‐LG AS patients.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT 01835028.

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Low-Gradient Aortic Stenosis

Abstract: Background-The prognostic value of dobutamine stress hemodynamic data in the setting of low-gradient aortic stenosis has been addressed in small, single-center studies. Larger studies are needed to define the criteria for selecting the patients who will benefit from valve replacement.

Cited by 530 publications

References 28 publications

Predictors of Mortality and Symptomatic Outcome of Patients With Low‐Flow Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

Predictors of Mortality and Symptomatic Outcome of Patients With Low‐Flow Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

The Role of Stress Echocardiography in Valvular Heart Disease: A Current Appraisal

Relationship Between QT Interval and Outcome in Low‐Flow Low‐Gradient Aortic Stenosis With Low Left Ventricular Ejection Fraction

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