Impact of Arterial Blood Pressure on Ultrasound Hemodynamic Assessment of Aortic Valve Stenosis Severity

Hayek, Ahmad; Dérimay, François; Green, Lisa; Rosset, Marion; Thibault, Hélène; Rioufol, Gilles; Finet, Gérard

doi:10.1016/j.echo.2020.06.013

Cited by 8 publications

(7 citation statements)

References 28 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Both impaired TVR and TAC were associated with a lower TPG for a given aortic valve stenosis. This association is also highly suggested by clinical and experimental data since the presence of arterial hypertension is associated with underestimated TPGs in patients with severe aortic stenosis [ 43 , 44 ]. In a recent study, the early return of arterial wave reflections (a parameter determined by both TAC and TVR) was associated with a lower TPG with a comparable AVA [ 45 ].…”

Section: Discussionmentioning

confidence: 86%

“…Furthermore, aortic stenosis generally coexists with arterial stiffening, which further increases the left ventricular afterload [ 31 , 38 ], and they are both the consequences of similar pathophysiological progress [ 34 ]. Clinical and experimental data show that, particularly in low flow states (either because of decreased myocardial contractility or increased afterload), the TPG may be low despite the presence of severe aortic stenosis, leading to diagnostic inaccuracies and therapeutic delays [ 40 , 41 , 42 , 43 , 44 , 45 ]. Repeating the measurement after pharmacological modulation of the cardiac output (dobutamine or nitrates infusion) is a classic strategy to address this issue by transiently increasing the stroke volume (SV); however, many exams still remain inconclusive, while significant side effects may be observed due to the administration of the vasoactive drugs [ 8 , 46 , 47 ]…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

The Impact of Left Ventricular Performance and Afterload on the Evaluation of Aortic Valve Stenosis: A 1D Mathematical Modeling Approach

et al. 2023

View full text Add to dashboard Cite

The transaortic valvular pressure gradient (TPG) plays a central role in decision-making for patients suffering from severe aortic stenosis. However, the flow-dependence nature of the TPG makes the diagnosis of aortic stenosis challenging since the markers of cardiac performance and afterload present high physiological interdependence and thus, isolated effects cannot be measured directly in vivo. We used a validated 1D mathematical model of the cardiovascular system, coupled with a model of aortic stenosis, to assess and quantify the independent effect of the main left ventricular performance parameters (end-systolic (Ees) and end-diastolic (Eed) elastance) and principal afterload indices (total vascular resistance (TVR) and total arterial compliance (TAC)) on the TPG for different levels of aortic stenosis. In patients with critical aortic stenosis (aortic valve area (AVA) ≤ 0.6 cm2), a 10% increase of Eed from the baseline value was associated with the most important effect on the TPG (−5.6 ± 0.5 mmHg, p < 0.001), followed by a similar increase of Ees (3.4 ± 0.1 mmHg, p < 0.001), in TAC (1.3 ±0.2 mmHg, p < 0.001) and TVR (−0.7 ± 0.04 mmHg, p < 0.001). The interdependence of the TPG left ventricular performance and afterload indices become stronger with increased aortic stenosis severity. Disregarding their effects may lead to an underestimation of stenosis severity and a potential delay in therapeutic intervention. Therefore, a comprehensive evaluation of left ventricular function and afterload should be performed, especially in cases of diagnostic challenge, since it may offer the pathophysiological mechanism that explains the mismatch between aortic severity and the TPG.

show abstract

Section: Discussionmentioning

confidence: 86%

Section: Introductionmentioning

confidence: 99%

The Impact of Left Ventricular Performance and Afterload on the Evaluation of Aortic Valve Stenosis: A 1D Mathematical Modeling Approach

et al. 2023

View full text Add to dashboard Cite

show abstract

“…If in fact her blood pressure had normalized during the TTE (as we show frequently happens) her case would be labeled as low gradient severe AS and should be treated. These discrepant care pathways emerge from the observation that transvalvular flow is significantly impacted by afterload [ 10 ]. And the integrative approach to grading this valve lesion incorporates afterload.…”

Section: Discussionmentioning

confidence: 99%

“…Blood pressure (BP) influences several echocardiogram based structural assessments including ventricular size, function, and apparent severity of valve lesions [ [1] , [2] , [3] ]. Systemic hypertension is common for patients with complex imaging phenotypes including heart failure [ 4 ], and left sided valve diseases [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

Blood pressure changes during routine transthoracic echocardiography

Kadwalwala

Downey

Patel

et al. 2023

International Journal of Cardiology Cardiovascular Risk and Pre

View full text Add to dashboard Cite

“…To attenuate the impact of high after load on TPG, it has been suggested that the assessment of the AS should be repeated after the intravenous or sublingual administration of nitrates (28)(29)(30)(31)(32)(33)(34). At conventional dosage, these potent vasodilators act on the wall of the small arteries but have no/little effect on arterioles, large arteries, or the aorta.…”

Section: Discussionmentioning

confidence: 99%

Arterial Wave Reflection and Aortic Valve Stenosis: Diagnostic Challenges and Prognostic Significance

Pagoulatou

Adamopoulos

Rovas

et al. 2022

Front. Cardiovasc. Med.

View full text Add to dashboard Cite

IntroductionArterial wave reflection is an important component of the left ventricular afterload, affecting both pressure and flow to the aorta. The aim of the present study was to evaluate the impact of wave reflection on transvalvular pressure gradients (TPG), a key parameter for the evaluation of aortic valve stenosis (AS), as well as its prognostic significance in patients with AS undergoing a transcatheter aortic valve replacement (TAVR).Materials and MethodsThe study population consisted of 351 patients with AS (mean age 84 ± 6 years, 43% males) who underwent a complete hemodynamic evaluation before the TAVR. The baseline assessment included right and left heart catheterization, transthoracic echocardiography, and a thorough evaluation of the left ventricular afterload by means of wave separation analysis. The cohort was divided into quartiles according to the transit time of the backward pressure wave (BWTT). Primary endpoint was all-cause mortality at 1 year.ResultsEarly arrival of the backward pressure wave was related to lower cardiac output (Q1: 3.7 ± 0.9 lt/min vs Q4: 4.4 ± 1.0 lt/min, p < 0.001) and higher aortic systolic blood pressure (Q1: 132 ± 26 mmHg vs Q4: 117 ± 26 mmHg, p < 0.001). TPG was significantly related to the BWTT, patients in the arrival group exhibiting the lowest TPG (mean TPG, Q1: 37.6 ± 12.7 mmHg vs Q4: 44.8 ± 14.7 mmHg, p = 0.005) for the same aortic valve area (AVA) (Q1: 0.58 ± 0.35 cm2 vs 0.61 ± 0.22 cm2, p = 0.303). In multivariate analysis, BWTT remained an independent determinant of mean TPG (beta 0.3, p = 0.002). Moreover, the prevalence of low-flow, low-gradient AS with preserved ejection fraction was higher in patients with early arterial reflection arrival (Q1: 33.3% vs Q4: 14.9%, p = 0.033). Finally, patients with early arrival of the reflected wave (Q1) exhibited higher all-cause mortality at 1 year after the TAVR (unadjusted HR: 2.33, 95% CI: 1.17–4.65, p = 0.016).ConclusionEarly reflected wave arrival to the aortic root is associated with poor prognosis and significant aortic hemodynamic alterations in patients undergoing a TAVR for AS. This is related to a significant decrease in TPG for a given AVA, leading to a possible underestimation of the AS severity.

show abstract

Impact of Arterial Blood Pressure on Ultrasound Hemodynamic Assessment of Aortic Valve Stenosis Severity

Cited by 8 publications

References 28 publications

The Impact of Left Ventricular Performance and Afterload on the Evaluation of Aortic Valve Stenosis: A 1D Mathematical Modeling Approach

The Impact of Left Ventricular Performance and Afterload on the Evaluation of Aortic Valve Stenosis: A 1D Mathematical Modeling Approach

Blood pressure changes during routine transthoracic echocardiography

Arterial Wave Reflection and Aortic Valve Stenosis: Diagnostic Challenges and Prognostic Significance

Contact Info

Product

Resources

About