Hemodynamics of paradoxical severe aortic stenosis: insight from a pressure–volume loop analysis

Gotzmann, Michael; Hauptmann, Sabine; Hogeweg, Maximilian; Choudhury, Dinah S.; Schiedat, Fabian; Dietrich, Johannes W.; Westhoff, Timm H.; Bergbauer, M; Mügge, Andreas

doi:10.1007/s00392-019-01423-z

Cited by 16 publications

(13 citation statements)

References 28 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Of particular interest, in distinct patients (e.g., with low-flow, low-grade AS), reduction of LV contractility could be also observed. 39 It must also be mentioned that although P-V analysis is currently considered the most adequate technique to measure in vivo cardiac function, it also possesses some limitations. In particular, E a was found to be relatively insensitive to pulsatile arterial load, and importantly, it does not account for the loading sequence.…”

Section: Limitationsmentioning

confidence: 99%

Longitudinal Strain Reflects Ventriculoarterial Coupling Rather Than Mere Contractility in Rat Models of Hemodynamic Overload–Induced Heart Failure

Ruppert

Lakatos

Braun

et al. 2020

Journal of the American Society of Echocardiography

View full text Add to dashboard Cite

Background: Longitudinal strain (LS) is a sensitive marker of systolic function. Recent findings suggest that both myocardial contractility and loading conditions determine LS. The aim of this study was to investigate whether LS reflects the connection of cardiac contractility to afterload (termed ventriculoarterial coupling [VAC]) rather than mere contractility in rat models of hemodynamic overload-induced heart failure (HF). Methods: Pressure overload-induced HF was evoked by transverse aortic constriction (TAC; n = 14). Volume overload-induced HF was established by an aortocaval fistula (ACF; n = 12). Age-matched sham-operated animals served as controls for TAC (n = 14) and ACF (n = 12), respectively. Pressure-volume analysis was carried out to compute contractility (slope of end-systolic pressure-volume relationship [ESPVR]), afterload (arterial elastance [E a ]), and VAC (E a /ESPVR). Preload was evaluated by meridional end-diastolic wall stress. Speckle-tracking echocardiography was performed to assess LS. Results: The TAC group presented with maintained ESPVR, increased E a , and enhanced meridional enddiastolic wall stress. In contrast, the ACF group was characterized by reduced ESPVR, decreased E a , and enhanced meridional end-diastolic wall stress. VAC increased in both HF groups. Furthermore, LS was also impaired in both HF models (À5.9 6 0.6% vs À12.9 6 0.5%, TAC vs Sham t [P < .001], and À11.7 6 0.7% vs À13.5 6 0.4%, ACF vs Sham a [P = .048]). Statistical analysis revealed that strain parameters were determined predominantly by afterload in the TAC group and by contractility in the ACF group, while preload had a minor effect. In the entire study population, LS showed a correlation with VAC (R = 0.654, P < .001) but not with ESPVR (R = 0.058, P = .668). Conclusions: Under pathophysiologic conditions when both contractility and afterload become altered, LS reflects VAC rather than mere contractility.

show abstract

Section: Limitationsmentioning

confidence: 99%

Longitudinal Strain Reflects Ventriculoarterial Coupling Rather Than Mere Contractility in Rat Models of Hemodynamic Overload–Induced Heart Failure

Ruppert

Lakatos

Braun

et al. 2020

Journal of the American Society of Echocardiography

View full text Add to dashboard Cite

show abstract

“…In brief, depressed LV systolic performance might result not from an apparent impairment of the intrinsic LV contractile state, but from a smaller LVd according to the Frank–Starling law. In patients with P-LFLG-AS, this mechanism was demonstrated by Gotzmann et al [ 27 ], who reported a decreased maximum rate of LV pressure rise during the isovolumetric contraction (dp/dt max ), but higher dp/dt max normalized for lower LV end-diastolic volume (i.e., the Starling contractile index) in P-LFLG-AS compared to NFHG-AS. That dp/dt max is independent of afterload enables the separation of the effect of afterload from that of preload and intrinsic LV properties on LV performance.…”

Section: Discussionmentioning

confidence: 76%

“…No significant intergroup differences in cESS despite a 1.7-fold higher Zva and 1.5-fold higher systemic arterial compliance might have reflected the impact of a smaller LV size and more concentric LV geometry which counterbalanced the effect of excessive arterial load on cESS in P-LFLG-AS. An increased Zva, especially its arterial component, is a typical feature of P-LFLG-AS [ 1 , 2 ], confirmed in both invasive [ 27 , 28 ] and noninvasive [ 8 ] studies. The maintenance of cESS at a constant level over time appears pivotal for an adequate hypertrophying response to chronic LV pressure overload.…”

Section: Discussionmentioning

confidence: 87%

Impaired Left Ventricular Circumferential Midwall Systolic Performance Appears Linked to Depressed Preload, but Not Intrinsic Contractile Dysfunction or Excessive Afterload, in Paradoxical Low-Flow/Low-Gradient Severe Aortic Stenosis

Długosz¹,

Surdacki

Zawiślak³

et al. 2022

JCM

View full text Add to dashboard Cite

Paradoxical low-flow/low-gradient aortic stenosis (P-LFLG-AS) occurs in about one-third of patients with severe AS and preserved left ventricular (LV) ejection fraction (EF). Our aim was to differentiate between altered LV loading conditions and contractility as determinants of subtle LV systolic dysfunction in P-LFLG-AS. We retrospectively analyzed medical records of patients with isolated severe degenerative AS and preserved EF (30 subjects with P-LFLG-AS and 30 patients with normal-flow/high-gradient severe AS (NFHG-AS)), without relevant coexistent diseases (e.g., diabetes, coronary artery disease and chronic kidney disease) or any abnormalities which could account for a low-flow state. Patients with P-LFLG-AS and NFHG-AS did not differ in aortic valve area index and most clinical characteristics. Compared to NFHG-AS, subjects with P-LFLG-AS exhibited smaller LV end-diastolic diameter (LVd) (44 ± 5 vs. 54 ± 5 mm, p < 0.001) (consistent with lower LV preload) with pronounced concentric remodeling, higher valvulo-arterial impedance (3.8 ± 1.1 vs. 2.2 ± 0.5 mmHg per mL/m2, p < 0.001) and diminished systemic arterial compliance (0.45 ± 0.11 vs. 0.76 ± 0.23 mL/m2 per mmHg, p < 0.001), while circumferential end-systolic LV midwall stress (cESS), an estimate of afterload at the LV level, was similar in P-LFLG-AS and NFHG-AS (175 ± 83 vs. 198 ± 69 hPa, p = 0.3). LV midwall fractional shortening (mwFS) was depressed in P-LFLG-AS vs. NFHG-AS (12.3 ± 3.5 vs. 14.7 ± 2.9%, p = 0.006) despite similar EF (61 ± 6 vs. 59 ± 8%, p = 0.4). By multiple regression, the presence of P-LFLG-AS remained a significant predictor of lower mwFS compared to NFHG-AS upon adjustment for cESS (β ± SEM: −2.35 ± 0.67, p < 0.001); however, the significance was lost after further correction for LVd (β = −1.10 ± 0.85, p = 0.21). In conclusion, the association of P-LFLG-AS with a lower cESS-adjusted mwFS, an index of afterload-corrected LV circumferential systolic function at the midwall level, appears secondary to a smaller LV end-diastolic cavity size according to the Frank–Starling law. Thus, low LV preload, not intrinsic contractile dysfunction or excessive afterload, may account for impaired LV circumferential midwall systolic performance in P-LFLG-AS.

show abstract

“…anemia, hyperthyreosis, etc.). In general, underestimation of AS severity by determining V max AS and ΔP mean AS may occur during low flow conditions, reduced LVSV and reduced LV function [17][18][19][20], overestimation during hyperdynamic circulatory states and by pressure recovery [21][22][23][24]. Pressure recovery describes the phenomenon of conversion of kinetic energy within the AS narrowing into pressure energy in the aortic root and the ascending aorta [23,25].…”

Section: Peak Jet Velocity (V Max As) and Mean Pressure Gradient (δP mentioning

confidence: 99%

Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation

Hagendorff¹,

Knebel²,

Helfen

et al. 2019

Clin Res Cardiol

View full text Add to dashboard Cite

According to recent recommendations on echocardiographic assessment of aortic valve stenosis direct measurement of transvalvular peak jet velocity, calculation of transvalvular mean gradient from the velocities using the Bernoulli equation and calculation of the effective aortic valve area by continuity equation are the appropriate primary key instruments for grading severity of aortic valve stenosis. It is obvious that no gold standard can be declared for grading the severity of aortic stenosis. Thus, conclusions of the exclusive evaluation of aortic stenosis by Doppler echocardiography seem to be questionable due to the susceptibility to errors caused by methodological limitations, mathematical simplifications and inappropriate documentation. The present paper will address practical issues of echocardiographic documentation to satisfy the needs to analyze different scenarios of aortic stenosis due to various flow conditions and pressure gradients. Transesophageal and multidimensional echocardiography should be implemented for reliable measurement of geometric aortic valve area and of cardiac dimensions at an early stage of the diagnostic procedure to avoid misinterpretation due to inconsistent results.

show abstract

Hemodynamics of paradoxical severe aortic stenosis: insight from a pressure–volume loop analysis

Cited by 16 publications

References 28 publications

Longitudinal Strain Reflects Ventriculoarterial Coupling Rather Than Mere Contractility in Rat Models of Hemodynamic Overload–Induced Heart Failure

Longitudinal Strain Reflects Ventriculoarterial Coupling Rather Than Mere Contractility in Rat Models of Hemodynamic Overload–Induced Heart Failure

Impaired Left Ventricular Circumferential Midwall Systolic Performance Appears Linked to Depressed Preload, but Not Intrinsic Contractile Dysfunction or Excessive Afterload, in Paradoxical Low-Flow/Low-Gradient Severe Aortic Stenosis

Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation

Contact Info

Product

Resources

About