Outcome and Impact of Aortic Valve Replacement in Patients With Preserved LVEF and Low-Gradient Aortic Stenosis

Dayan, Víctor; Vignolo, Gustavo; Magné, Julien; Clavel, Marie‐Annick; Mohty, Dania; Pîbarot, Philippe

doi:10.1016/j.jacc.2015.09.076

Cited by 163 publications

(89 citation statements)

References 33 publications

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“…Among patients with discordant‐AS grading (ie, small AVA but low gradient: Low‐Flow, Low‐Gradient and Normal‐Flow, Low‐Gradient), 50% have severe aortic valve calcification as measured by multidetector computed tomography 14. Recent meta‐analyses reported that aortic valve replacement is associated with major survival benefit in both Low‐Flow, Low‐Gradient and Normal‐Flow, Low‐Gradient AS 15, 16. However, in current clinical guidelines, Normal‐Flow, Low‐Gradient patients are considered as moderate AS and there is no specific recommendation for referral to aortic valve replacement in these patients 17…”

Section: Introductionmentioning

confidence: 99%

Impact of Vascular Hemodynamics on Aortic Stenosis Evaluation: New Insights Into the Pathophysiology of Normal Flow—Small Aortic Valve Area—Low Gradient Pattern

Côté

Simard

Zenses

et al. 2017

JAHA

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BackgroundAbout 50% of normal‐flow/low‐gradient patients (ie, low mean gradient [MG] or peak aortic jet velocity and small aortic valve area) have severe aortic valve calcification as measured by computed tomography. However, they are considered to have moderate aortic stenosis (AS) in current American College of Cardiology/American Heart Association guidelines. The objective was thus to evaluate the effect of hypertension and reduced arterial compliance (rAC) on MG and Vpeak measurements.Methods and ResultsDoppler‐echocardiography was performed in 4 sheep with experimentally induced severe and critical AS at: (1) normal aortic pressure, (2) during hypertension, and (3) with rAC. Hypertension and rAC induced a substantial decrease in MG/Vpeak compared with normal stage (both P≤0.03) despite a stable transvalvular flow (P>0.16). Hypertension and rAC resulted in a greater reduction of MG in critical (−42%) compared with severe (−35%) AS (P˂0.0001). Comprehensive Doppler‐echocardiography and computed tomography were performed in 220 AS patients (mean age: 69±13 years; MG 29±18 mm Hg) with normal flow. The population was divided in 3 groups according to the presence of hypertension and rAC. The slope of the linear association between MG/Vpeak and aortic valve calcification divided by the cross‐sectional area of the aortic annulus was significantly reduced in patients with hypertension and/or rAC compared with normotensive/normal AC patients (P<0.01). Accordingly, patients with normal‐flow/low‐gradient and severe aortic valve calcification density were more frequent in hypertension and rAC groups compared with the normotensive/normal‐AC group (16% and 12% compared with 2%; P=0.03).ConclusionsHypertension and rAC are associated with a substantial reduction in MG/Vpeak for similar aortic valve calcification (ie, similar AS anatomic severity), which may lead to underestimation of AS hemodynamic severity.

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Section: Introductionmentioning

confidence: 99%

Impact of Vascular Hemodynamics on Aortic Stenosis Evaluation: New Insights Into the Pathophysiology of Normal Flow—Small Aortic Valve Area—Low Gradient Pattern

Côté

Simard

Zenses

et al. 2017

JAHA

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“…LF is often associated with a low gradient (LG; mean transvalvular gradient <40 mmHg) of the aortic valve despite severe AS. 4 Patients with classical LF have a poor prognosis with medical treatment but a higher operative mortality than patients with normal flow (NF) AS. 1 Patients with paradoxical LF also have a worse prognosis with medical therapy than with surgical aortic valve replacement (AVR), despite higher operative mortality.…”

Section: Methodsmentioning

confidence: 99%

Independent Effect of Low Flow on Outcomes in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis

Miyazaki

Kuwaki

Kajimoto

et al. 2018

Circ J

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Background: Low flow (LF; i.e., reduced left ventricular stroke volume index <35 mL/m 2 ) can occur with severe aortic stenosis (AS). However, few studies have investigated the effects of LF on early and late outcomes after aortic valve replacement (AVR) for severe AS. Methods and Results:In all, 285 severe AS patients undergoing isolated AVR at Juntendo University Hospital between August 2002 and August 2015 were enrolled in the study. In this cohort, 52 patients (18%) had LF. Compared with patients with normal flow (NF) severe AS, early postoperative mortality (9.6% vs. 1.2%; P=0.006), gastrointestinal complications (5.7% vs. 0.8%; P=0.04), and the duration of the intensive care unit (ICU) stay (81.7 vs. 35.3 h; P=0.02) were increased in LF patients with severe AS. LF was an independent predictor of early mortality (Model A, odds ratio [OR] 6.81, P=0.01; Model B, OR 6.69, P=0.01) and composite complications (Model A, OR 2.44, P=0.02). In propensity score-matched comparisons, early mortality (12.8% vs. 0%; P=0.02), composite complications (28.2% vs. 10.2%; P=0.04), and duration of ICU stay (97.4 vs. 22.1 h; P=0.006) were significantly increased in LF than NF patients.Conclusions: LF, as an important independent risk factor for postoperative mortality and morbidity, should be included in risk stratification and assessment in severe AS patients.

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“…han brindado esclarecimientos importantes en esta entidad con claridad acerca de la toma de decisiones que aún deben ser orientadas, pero con una clasificación basada en una combinación de volumen de latido indexado y gradiente transvalvular promedio. [26][27][28][29][30] Una vez que está presente una estenosis aórtica significativa, el diagnóstico es relativamente directo, pero las imágenes aumentan la comprensión del interjuego valvuloarterial en el que la compliance arterial sistémica, resistencia vascular e impedancia valvular afectan al ventrículo izquierdo (VI). Una enfermedad común tal como la hipertensión con estenosis aórtica eleva la impedancia en serie y, cuando se acopla con aumento de la rigidez aórtica, acompaña al envejecimiento y la ateroesclerosis y contribuye a la carga del VI y el desarrollo de los síntomas en una forma importante.…”

Section: Enfermedad Valvular Cardíacaunclassified

The Future of Cardiovascular Imaging

2016

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O ver the past 2 decades, we have witnessed an explosive expansion in the armamentarium of noninvasive and invasive imaging technologies capable of providing detailed information about the structure and function of the heart and vasculature. Many of these technologies are integrative (eg, positron emission tomography and computed tomography, positron emission tomography and MRI), thereby compounding the unique strengths of the component technologies to achieve unprecedented improvements to our ability to diagnose disease, improve patient care, and advance biomedical research. In addition, the miniaturization of imaging devices with dramatic increases in sensitivity and spatial resolution, coupled with the development of quantitative molecular imaging approaches for evaluating physiology and pathobiology at the cellular and molecular levels, provides a unique platform for a new era in diagnostic imaging. The crucial role of imaging in early phenotyping of disease, risk assessment, and management guidance is expanding rapidly in ways previously thought unrealistic.Along with clinical, molecular, and genomewide association studies, structural and functional quantitative imaging already plays a critical role in phenotyping cardiovascular disease. Unique strengths of imaging phenotyping include its ability to provide precise, organ-specific anatomic localization and quantification of disease traits, to demonstrate and quantify involvement of other organs in cardiac disease, to provide an opportunity to investigate the time course of disease-specific molecular events in vivo, and to track their response to therapy. In so doing, quantitative structural and functional imaging can provide a nuanced description of disease burden (eg, atherosclerosis, myocarditis), disease subtypes (eg, amyloidosis), and, importantly, the relationship between the specific phenotype and outcomes, thereby informing treatment strategies and allowing more personalized approaches to patient management.Our objectives for this article are to (1) provide a viewpoint regarding the evolving role of cardiovascular imaging in biomedical research and clinical practice, (2) discuss the challenges associated with clinical translation of imaging innovations and the opportunities for multimodality imaging in the changing paradigm of value-based medicine, and (3) briefly outline future challenges and opportunities including the requirements for training future generations of imaging scientists and clinical specialists. Unlike traditional reviews that provide a detailed discussion of the role of 1 or more imaging modalities in cardiovascular (CV) disease, our discussion will focus on the potential role of imaging in what we believe are key areas of the translational highway with specific examples on how structural and functional imaging may contribute to scientific discovery, diagnosis, risk stratification, and patient management in each of those areas. Redefining the Role of Imaging Across the Continuum of Biomedical Research and Clinical Practice Translati...

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Outcome and Impact of Aortic Valve Replacement in Patients With Preserved LVEF and Low-Gradient Aortic Stenosis

Abstract: Patients with paradoxical LF-LG AS and NF-LG AS have increased risk of mortality compared with other subtypes of AS with preserved left ventricular ejection fraction, and improved outcome with AVR.

Cited by 163 publications

References 33 publications

Impact of Vascular Hemodynamics on Aortic Stenosis Evaluation: New Insights Into the Pathophysiology of Normal Flow—Small Aortic Valve Area—Low Gradient Pattern

Impact of Vascular Hemodynamics on Aortic Stenosis Evaluation: New Insights Into the Pathophysiology of Normal Flow—Small Aortic Valve Area—Low Gradient Pattern

Independent Effect of Low Flow on Outcomes in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis

The Future of Cardiovascular Imaging

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