Low-Gradient, Low-Flow Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction

Tribouilloy, Christophe; Ruşinaru, Dan; Maréchaux, Sylvestre; Castel, Anne-Laure; Debry, Nicolas; Maizel, Julien; Mentaverri, Romuald; Kamel, Saı̈d; Slama, Michel; Lévy, F.

doi:10.1016/j.jacc.2014.09.080

Cited by 174 publications

(115 citation statements)

References 24 publications

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“…10-14 A significant reason for grading discordance has been attributed to the existence of a distinct subtype of aortic valve disease, lowflow AS with preserved EF, also known as "paradoxical AS," which can occur in patients with LV hypertrophy in the context of small LV size, right heart dysfunction, diastolic dysfunction, or moderate or severe mitral regurgitation. 13,[15][16][17][18] Likewise, grading discordance is greater during pre-CPB TEE compared with preoperative TTE, even when controlling for LVEF and mitral regurgitation. 19 Approximately 51% of patients undergoing AVR or AVR with CABG exhibit discordance between PG m and AVA grading across all grades (mild, moderate, and severe) of AS during pre-CPB TEE.…”

Section: Discussionmentioning

confidence: 99%

Grading Aortic Stenosis With Mean Gradient and Aortic Valve Area: A Comparison Between Preoperative Transthoracic and Precardiopulmonary Bypass Transesophageal Echocardiography

Whitener

Sivak

Akushevich

et al. 2016

Journal of Cardiothoracic and Vascular Anesthesia

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Objective: The authors hypothesized that average precardiopulmonary bypass (pre-CPB) transesophageal echocardiographic (TEE) mean gradient (PG m ) and aortic valve area (AVA) values would be significantly different from preoperative transthoracic (TTE) values in the same patients and that these changes would affect pre-CPB TEE grading of aortic stenosis (AS).Design: Retrospective, observational design. Setting: Single university hospital. Participants: The study comprised 92 patients who underwent aortic valve replacement with or without coronary artery bypass grafting between 2000 and 2012 at Duke University Hospital and who had PG m and AVA values recorded in both pre-CPB TEE and preoperative TTE reporting databases.Interventions: None. Measurements and Main Results: PG m with pre-CPB TEE was lower by 6.6 mmHg (95% confidence interval, -4.0 to -9.3 mmHg; p o 0.001), whereas AVA was higher by 0.10 cm 2 (95% confidence interval, 0.04 to 0.15 cm 2 ; p o 0.001), compared with preoperative TTE values. When using PG m , pre-CPB TEE generated an AS severity 1 grade lower 39.1% of the time and revealed no difference 55.4% of the time compared to preoperative TTE. When using AVA by continuity, pre-CPB TEE generated an AS severity 1 grade lower 14.1% of the time and revealed no difference 81.5% of the time compared to preoperative TTE. When using either PGm or AVA, preoperative TTE exhibited moderate or severe AS for all study patients, whereas, pre-CPB TEE demonstrated mild AS in 5.4% (n ¼ 92) of patients.Conclusions: The authors confirmed their hypothesis that pre-CPB TEE generates different PG m and AVA values compared with preoperative TTE. These differences often underestimate AS severity. Hemodynamic standardizations or adjustments of pre-CPB TEE PG m and AVA values may be necessary in anesthetized patients before assigning an AS grade using these parameters. & 2016 Elsevier Inc. All rights reserved.KEY WORDS: aortic stenosis, aortic valve area, discordance, mean gradient, precardiopulmonary bypass (intraoperative) transesophageal echocardiography P RECARDIOPULMONARY BYPASS (pre-CPB) transesophageal echocardiography (TEE) is essential for intraoperative assessment and surgical guidance during cardiac surgery. Although many patients come to the operating room with an extensive cardiac workup, pre-CPB TEE aortic valve assessment can affect surgical decision-making based on new findings during planned or emergency surgeries. According to a large retrospective review of 3,835 patients undergoing isolated coronary artery bypass grafting (CABG), 3.3% of patients had an unplanned aortic or mitral valve procedure added to the surgery based on pre-CPB TEE findings. 1 Of 1,823 patients undergoing mitral valve surgery, 1.0% of patients underwent an unplanned aortic valve procedure based on incidental findings during pre-CPB TEE. 1 Given that surgical decisions can be based on pre-CPB TEE findings, accurate interpretation of grading parameters during the pre-CPB period is imperative.The validated mean gradient (PG m ) and aor...

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Section: Discussionmentioning

confidence: 99%

Grading Aortic Stenosis With Mean Gradient and Aortic Valve Area: A Comparison Between Preoperative Transthoracic and Precardiopulmonary Bypass Transesophageal Echocardiography

Whitener

Sivak

Akushevich

et al. 2016

Journal of Cardiothoracic and Vascular Anesthesia

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“…Peak aortic velocity was recorded using continuous‐wave Doppler in several acoustic windows (apical 5‐chamber, right parasternal, suprasternal, epigastric views) 12. The highest aortic velocity was used to calculate aortic time–velocity integral, MPG, and V max .…”

Section: Methodsmentioning

confidence: 99%

Prognostic Value of Aortic Valve Area by Doppler Echocardiography in Patients With Severe Asymptomatic Aortic Stenosis

Maréchaux

Ringlé

Ruşinaru

et al. 2016

JAHA

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BackgroundThe aim of this study was to evaluate the relationship between aortic valve area (AVA) obtained by Doppler echocardiography and outcome in patients with severe asymptomatic aortic stenosis and to define a specific threshold of AVA for identifying asymptomatic patients at very high risk based on their clinical outcome.Methods and ResultsWe included 199 patients with asymptomatic severe aortic stenosis (AVA ≤1.0 cm2). The risk of events (death or need for aortic valve replacement) increased linearly on the scale of log hazard with decreased AVA (adjusted hazard ratio 1.17; 95% CI 1.06–1.29 per 0.1 cm2 AVA decrement; P=0.002). Event‐free survival at 12, 24, and 48 months was 63±6%, 51±6%, and 34±6%, respectively, for AVA 0.8 to 1 cm2; 49±6%, 36±6%, and 26±6%, respectively, for AVA 0.6 to 0.8 cm2; and 33±8%, 20±7%, and 11±5%, respectively, for AVA ≤0.6 cm2 (P trend=0.002). Patients with AVA ≤0.6 cm2 had a significantly increased risk of events compared with patients with AVA 0.8 to 1 cm2 (adjusted hazard ratio 2.22; 95% CI 1.41–3.52; P=0.001), whereas patients with AVA 0.6 to 0.8 cm2 had an increased risk of events compared with those with AVA 0.8 to 1 cm2, but the difference was not statistically significant (adjusted hazard ratio 1.38; 95% CI 0.93–2.05; P=0.11). After adjustment for covariates and aortic valve replacement as a time‐dependent variable, patients with AVA ≤0.6 cm2 had a significantly greater risk of all‐cause mortality than patients with AVA >0.6 cm2 (hazard ratio 3.39; 95% CI 1.80–6.40; P<0.0001).ConclusionsPatients with severe asymptomatic aortic stenosis and AVA ≤0.6 cm2 displayed an important increase in the risk of adverse events during short‐term follow‐up. Further studies are needed to determine whether elective aortic valve replacement improves outcome in this high‐risk subgroup of patients.

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“…Initial reports showed a poorer prognosis in comparison to patients with high gradient AS, while a recent study has provided evidence for comparable outcomes of PLF-LGAS to that of patients with a moderate AS [47].…”

Section: Native Aortic Valve Regurgitationmentioning

confidence: 97%

Transcatheter aortic valve implantation. Expert Consensus of the Association of Cardiovascular Interventions of the Polish Cardiac Society and the Polish Society of Cardio-Thoracic Surgeons, approved by the Board of the Polish Cardiac Society…

et al. 2017

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Low-Gradient, Low-Flow Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction

Cited by 174 publications

References 24 publications

Grading Aortic Stenosis With Mean Gradient and Aortic Valve Area: A Comparison Between Preoperative Transthoracic and Precardiopulmonary Bypass Transesophageal Echocardiography

Grading Aortic Stenosis With Mean Gradient and Aortic Valve Area: A Comparison Between Preoperative Transthoracic and Precardiopulmonary Bypass Transesophageal Echocardiography

Prognostic Value of Aortic Valve Area by Doppler Echocardiography in Patients With Severe Asymptomatic Aortic Stenosis

Transcatheter aortic valve implantation. Expert Consensus of the Association of Cardiovascular Interventions of the Polish Cardiac Society and the Polish Society of Cardio-Thoracic Surgeons, approved by the Board of the Polish Cardiac Society…

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