Low Flow Low Gradient Severe Aortic Stenosis: Diagnosis and Treatment

Abstract

Approximately 40% of patients with aortic stenosis (AS) show discordant Doppler-echocardiographic parameters with aortic valve area (AVA) <1 cm 2 and/or index iAVA <0.6 cm 2 /m 2 (consistent with severe AS) and the mean gradient (MG) <40 mmHg, consistent with mild/moderate AS. Accurate diagnosis of true severe low flow low gradient AS versus pseudo-severe aortic stenosis is important for prognosis and optimal timing for intervention. Doppler echocardiography using intravenous low dose dobutamine challenge is widely used for differentiating pseudo-severe from true severe aortic stenosis. However, relying on echocardiography alone may have limitations in accurate diagnosis. Reliable diagnosis using echocardiography is dependent on multiple factors like the angle of interrogation of the aortic jet, the assumption that the LVOT area is circular in cross section, optimal echo windows, the presence of underlying subclinical coronary artery disease prior to dobutamine challenge etc. In this chapter, we describe non-invasive and invasive strategies to assess the aortic valve using dobutamine stress. Direct measurement of gradients across the aortic valve while estimating the change in cardiac output and aortic valve area with increments of dobutamine infusion dose is complementary, safe and useful when conventional echocardiography techniques are inconclusive. Finally, the chapter describes effective strategies of treatment for low gradient severe aortic stenosis, including the role for diagnostic balloon valvuloplasty, in the era of transcatheter valve replacement (TAVR).

Cardiorespiratory effects of different intraabdominal pressures in sheep: An experimental study

“…PVF Vel and GrFAo (Table 1) were within normal values, but decreased in all groups at FINAL, which, according to Mohamad Ali et al (2019) is due to flow velocities decrease along with SV. In this study, the animals used had no previous cardiorespiratory alterations, leading to these findings reflecting no impairment of the right ventricle function, which was the opposite observed by Chemonges et al (2020) in sheep with smoke‐induced lung injury during extracorporeal membrane oxygenation presenting decreasing values of right ventricular stroke work index among other findings over time.…”

“…Finally, PVF Vel showed a negative correlation with Δ P , RS in G3 (Table 4, Figure 2), which may reflect an association between flow velocities decreasing along with SV (Mohamad Ali et al, 2019) and decreased respiratory system compliance and/or lung volume expressed by higher values of Δ P , RS . Accordingly, in G3, a positive correlation was observed between V d/ V t and Ppeak, RS , Pplat, RS , Δ P , RS , and PaCO 2 (Table 4, Figure 2).…”