Paradoxical Low-Flow, Low-Gradient Aortic Stenosis

Pîbarot, Philippe; Dumesnil, Jean G.

doi:10.1161/circulationaha.113.005718

Cited by 53 publications

(52 citation statements)

References 14 publications

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“…This could partly explain the high variability in the prevalence of low-flow, low-gradient AS in the different series published. [17][18][19][20][21][22][23][24] Although the reproducibility is similar in both LVOT measurements with 2D TTE, given the better correlation of LVOT diameter at the HP with 3D TEE, measurement of LVOT dimensions at the HP could be advocated as the reference approach.…”

Section: Discussionmentioning

confidence: 99%

Three-Dimensional Morphology of the Left Ventricular Outflow Tract: Impact on Grading Aortic Stenosis Severity

Caballero

Saura

Oliva-Sandoval

et al. 2017

Journal of the American Society of Echocardiography

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Section: Discussionmentioning

confidence: 99%

Three-Dimensional Morphology of the Left Ventricular Outflow Tract: Impact on Grading Aortic Stenosis Severity

Caballero

Saura

Oliva-Sandoval

et al. 2017

Journal of the American Society of Echocardiography

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“…[2][3][4] Parikh and colleagues 1 laudably applied rigorous echocardiographic standards and measured the LVSVI for additional clarity in their diagnosis of LFLGAS, consistent with current guidelines. 2 The standards used in this study, however, may not necessarily be reproducible in all centers for the reliable diagnosis of LFLGAS.…”

mentioning

confidence: 83%

“…Variability of outflow tract anatomy and Doppler angle placement may commonly impair precise echocardiographic assessment of flow and of calculated valve area. 3,4 In the setting of LFLGAS and low EF, adjunctive catheterization or dobutamine testing is often used to differentiate true valve severity from a state of low output and only moderate aortic stenosis. 5 Furthermore, the diagnosis of paradoxic LFLGAS may be confounded by multiple factors, such as impaired diastolic filling, compromised longitudinal systolic function, atrial fibrillation, obesity, heart failure, and the presence of significant mitral or tricuspid valve regurgitation or stenosis.…”

mentioning

confidence: 99%

The paradox of surgical management of patients with low-flow, low-gradient aortic stenosis

Badhwar

Ikonomidis

Jacobs

2015

The Journal of Thoracic and Cardiovascular Surgery

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See related article on pages 1558-66.In this issue of the Journal, Parikh and colleagues 1 elegantly analyze the institutional outcomes of aortic valve replacement (AVR) at the Cleveland Clinic to illustrate the potential impact of low-flow, low-gradient aortic stenosis (LFLGAS) on 5-year post-AVR mortality. Despite quite acceptable initial operative outcomes, a fifth of their 875 consecutive patients who underwent surgical AVR for severe stenosis during a 2-year period were dead at 5 years. Preoperative left ventricular stroke volume index (LVSVI) was used to identify both LFLGAS with low ejection fraction (EF) and paradoxic LFLGAS with an EF of 50% or greater. It was determined that either variant of LFLGAS independently predicted early mortality.The natural history of LFLGAS with low EF and paradoxic LFLGAS has long been linked to mortality, yet its diagnosis and management remain challenging. [2][3][4] Parikh and colleagues 1 laudably applied rigorous echocardiographic standards and measured the LVSVI for additional clarity in their diagnosis of LFLGAS, consistent with current guidelines. 2 The standards used in this study, however, may not necessarily be reproducible in all centers for the reliable diagnosis of LFLGAS. The echocardiographic assessment of valve area by the continuity equation involves an estimation of flow on the basis of an assumption of left ventricular outflow tract circularity. Variability of outflow tract anatomy and Doppler angle placement may commonly impair precise echocardiographic assessment of flow and of calculated valve area. 3,4 In the setting of LFLGAS and low EF, adjunctive catheterization or dobutamine testing is often used to differentiate true valve severity from a state of low output and only moderate aortic stenosis. 5 Furthermore, the diagnosis of paradoxic LFLGAS may be confounded by multiple factors, such as impaired diastolic filling, compromised longitudinal systolic function, atrial fibrillation, obesity, heart failure, and the presence of significant mitral or tricuspid valve regurgitation or stenosis. 3,6 In response, some have advocated the use of cardiac magnetic resonance imaging as a more precise diagnostic tool that may simultaneously detect potential outcome-influencing myocardial fibrosis. 4,7 Nevertheless, when accurately diagnosed, LFLGAS is a known marker of reduced survival. [2][3][4][5][6][7] Parikh and colleagues 1 clearly demonstrate that LVSVI and the subtype of aortic stenosis have an influence on 5-year mortality after AVR. They note that for paradoxic LFLGAS the hazard ratio was 1.48 (95% confidence interval [CI] of 1.15-1.88), whereas LFLGAS with low EF had a hazard ratio of 2.03 (95% CI of 1.41-2.93). It is of comparative interest that their univariable hazard ratios associated with preoperative dialysis and reoperative cardiac surgery were 3.97 (95% CI of 2.12-7.43) and 2.07 (95% CI of 1.48-2.92), respectively. In a recent similar analysis of 1154 patients undergoing AVR, Clavel and associates 8 also found that LVSVI was an important preoperat...

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“…[23][24][25][26][27] However, low flow, defined as stroke volume index less than 35 mL/m 2 , has been strongly associated with poor outcomes post-TAVR regardless of ejection fraction. [23][24][25][26][27][28] Herrmann and colleagues 25 examined the outcomes of 971 PARTNER cohort A and B participants stratified by the presence of low or normal flow. For all patients treated, low flow aortic stenosis was observed in 530 patients (55%); low flow and low ejection fraction in 225 patients (23%); and a combination of low flow, low ejection fraction, and low gradient (<40 mm Hg) in 147 patients (15%).…”

Section: Low-flow Aortic Stenosismentioning

confidence: 99%