Paradoxical Low Flow Aortic Valve Stenosis: Incidence, Evaluation, and Clinical Significance

Clavel, Marie‐Annick; Pîbarot, Philippe; Dumesnil, Jean G.

doi:10.1007/s11886-013-0431-x

Cited by 22 publications

(9 citation statements)

References 30 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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“…13 Reduced stroke volume (eg, low flow [LF]) leads to a reduced pressure gradient despite severe AS creating the entity of "LF-lowgradient (LG) AS." 14 This can be further subdivided into a "classic" type with reduced LV-EF and a "paradoxical" type with preserved LV-EF, with the latter characterized by impaired longitudinal deformation, diastolic dysfunction, and a small LV volume causing the impairment in LV function. 15 LF states are associated with either poor prognosis, if treated medically, 16 or with increased operative mortality, if treated by surgical aortic valve replacement [16][17][18] or TAVR.…”

mentioning

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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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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“…(5-7) Due to the low flow status, in these patients generally low transvalvular gradients (<40 mmHg) are observed despite the presence of severe valvular stenosis and preserved LVEF, hence the term "paradoxical". 7,9,12 It is precisely this discordant classification that leads to uncertainty about the indication of AVR in this subgroup or, even worse, to the underestimation of the severity of the stenosis. 7,9,12 In addition, the lack of correlation between the classification criteria may be related to several factors, such as small patient body surface or errors in LVOT or velocity/gradient measurement, 12,13 per what these possibilities must be excluded before making the diagnosis of paradoxical AS.…”

Section: Definition and Diagnostic Difficultiesmentioning

confidence: 99%

“…7,9,12 It is precisely this discordant classification that leads to uncertainty about the indication of AVR in this subgroup or, even worse, to the underestimation of the severity of the stenosis. 7,9,12 In addition, the lack of correlation between the classification criteria may be related to several factors, such as small patient body surface or errors in LVOT or velocity/gradient measurement, 12,13 per what these possibilities must be excluded before making the diagnosis of paradoxical AS. 6,14 It is also important to bear in mind that the presence of arterial hypertension at the time of the study can lead to an erroneous diagnosis, since it could decrease the transvalvular gradients, 14,15 so the severity of the disease should be re-evaluated when the patient reaches normal blood pressure values.…”

Section: Definition and Diagnostic Difficultiesmentioning

confidence: 99%

Paradoxical aortic stenosis: much more than a classification problem

Fj¹

2018

JCCR

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Aortic stenosis (AS) is the most frequent valvular pathology and is one of the most common indications of valve replacement surgery. Its main form of presentation is calcified AS, whose prevalence increases proportionally with age. The indication of aortic valve replacement (AVR) is clear when the echocardiographic parameters of severity are coincident with each other and the patient presents symptoms, deterioration of the left ventricular ejection fraction (LVEF) or other indication of cardiac surgery. But with the advancement of diagnostic methods, new classifications of this condition have emerged. The term "paradoxical low-flow, low-gradient aortic stenosis" appears, which refers to the presence of an aortic valve area (AVA) <1 cm 2 or indexed AVA <0.6 cm 2 /m 2 , associated with low transvalvular flow and gradients, but with preserved LVEF (≥50%). This combination of data leads to a discordant classification (AVA in range of severity, medium gradient with values of mild to moderate disease). Due to the probability of potential errors that could underestimate the AVA by Doppler echo, and the uncertainty about the real meaning of this pathology, it is necessary to confirm the veracity of these findings, to give a correct diagnosis and treatment to patients with this intriguing entity.

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Paradoxical Low Flow Aortic Valve Stenosis: Incidence, Evaluation, and Clinical Significance

Cited by 22 publications

References 30 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

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

Paradoxical aortic stenosis: much more than a classification problem

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