Impact of Aortic Valve Replacement on Outcome of Symptomatic Patients With Severe Aortic Stenosis With Low Gradient and Preserved Left Ventricular Ejection Fraction

Abstract

P=0.22). Conclusions-AVR Ozkan et al AVR and Low-Gradient Severe AS 623We sought to compare the outcome of LGSAS patients who underwent AVR with those who received medical therapy. Methods Patient SelectionWe studied 1745 patients with symptomatic severe AS, based on AVA ≤1 cm 2 /m 2 , referred to our center from 2006 to 2011 for highrisk AS management (including possible valve replacement with either transcatheter AVR [TAVR] or surgical AVR [SAVR]). After exclusion of 157 patients with severe mitral or aortic valvular regurgitation, severe mitral stenosis, prosthetic heart valves, history of previous balloon aortic valvuloplasty, and indexed AVA >0.6 cm 2 /m 2 , a prospective group of 1588 patients with symptomatic severe AS (indexed AVA ≤0.6 cm 2 /m 2 ) was evaluated, of whom 260 (16%) had low transvalvular gradients (mean gradient <40 mm Hg; Figure 1). The study protocol was approved by the Institutional Review Board at the Cleveland Clinic. Clinical EvaluationAll 260 patients with LGSAS underwent a comprehensive medical history and physical examination. Angina was classified by Canadian Cardiovascular Society classification, dyspnea was evaluated by New York Heart Association class, and history of syncope was sought carefully. Demographic data, including age, sex, body mass index, and body surface area (BSA), and comprehensive clinical data, including history of hypertension, diabetes mellitus, dyslipidemia, smoking, coronary artery disease, peripheral arterial disease, prior myocardial infarction, and coronary artery bypass surgery, were collected. Current medications used by these patients were recorded.Systolic and diastolic blood pressures were measured at the time of echocardiographic examination, and mean arterial pressure was calculated. Society of Thoracic Surgery (STS) scores were calculated with an online risk calculator (http://riskcalc.sts.org/ STSWebRiskCalc273/). Echocardiographic AssessmentComprehensive baseline transthoracic echocardiograms that included standard M-mode, 2-dimensional color Doppler and pulsed-wave and continuous-wave Doppler were performed with commercially available systems. Left ventricular (LV) dimensions, volumes, and ejection fraction (using the biplane Simpson method), fractional shortening, LV mass, and relative wall thickness were calculated in accordance with the current recommendations.3 LV mass was indexed to BSA, and LV hypertrophy was defined as LV mass index >115 g/m 2 in men and >95 g/m 2 in women. LV midwall fractional shortening (MWFS) was also calculated from the formula MWFS=100×[(LVIDd/2+PWTd /2)−(LVIDs/2+PWTs/2)]/(LVIDd/2+PWTd/2), in which LVIDd is LV internal diameter in diastole, PWTd is posterior wall thickness in diastole, LVIDs is LV internal diameter in systole, and PWTs is posterior wall thickness in systole. Biplane left atrial volumes were measured from apical 2-and 4-chamber views and indexed to the BSA.A comprehensive diastolic examination was completed with Doppler echocardiography: Diastolic dysfunction was graded as grade 1(impaired relaxat...

Paradoxical Low-Flow, Low-Gradient Aortic Stenosis

“…The data published in the literature, [3][4][5]7,9,11,13,14 including those of the present study, 6 suggest that symptomatic patients with paradoxical LF/LG and evidence of severe AS should undergo AVR, whereas asymptomatic patients should probably be treated conservatively and followed closely. Regardless of the therapeutic decision described above (AVR versus conservative), patients with paradoxical LF/LG should be systematically screened for the presence of abnormal arterial hemodynamics, and, depending on the results of this screening, antihypertensive therapy should be instituted or optimized.…”

“…6,7,9 However, one cannot exclude that a proportion of the patients with NF/LG, and particularly of those included in categories 2 and 3 mentioned above, have true severe AS and may thus benefit from AVR. To this effect, Dumesnil et al 5 and Ozkan et al 14 reported that patients with NF/LG treated medically have poor outcomes and that AVR is associated with improved survival in both LF/LG and NF/LG AS. As opposed to other studies, 6,7,9 these 2 studies 5,14 have used an indexed AVA <0.6 cm 2 /m 2 instead of an AVA <1.0 cm 2 as inclusion criteria, therefore excluding patients having a low gradient attributable to a small body size (i.e., category 1).…”

Aortic Stenosis Suspected to Be Severe Despite Low Gradients

“…Several studies 10,14,[26][27][28][29][30][31] published recently provide further support for this recommendation.…”

Incremental Prognostic Value of Left Ventricular Global Longitudinal Strain in Patients With Aortic Stenosis and Preserved Ejection Fraction

“…9,10 In addition, risk-stratification in patients with low-gradient severe AS (paradoxical severe AS) may be clinically challenging, especially as there are limited reports of outcome in these patients. 11 The aim of this study was to assess the utility of LV-GLS in Background-We sought to assess the utility of left ventricular global longitudinal strain (LV-GLS) in predicting mortality in moderate to severe and paradoxical severe aortic stenosis (AS) patients with preserved ejection fraction. Methods and Results-We studied 395 AS patients (70±14 years, 57% men) with aortic valve area <1.3 cm 2 evaluated between January to June 2008 (excluding severe other valve disease and LV ejection fraction <50%).…”