Stress Echocardiography to Assess Stenosis Severity and Predict Outcome in Patients With Paradoxical Low-Flow, Low-Gradient Aortic Stenosis and Preserved LVEF

Clavel, Marie‐Annick; Ennezat, Pierre Vladimir; Maréchaux, Sylvestre; Dumesnil, Jean G.; Capoulade, Romain; Hachicha, Zeineb; Mathieu, Patrick; Bellouin, Annaïk; Bergeron, Sébastien; Meimoun, Patrick; Arsenault, Marie; Tourneau, Thierry Le; Pasquet, Agnès; Couture, Christian; Pîbarot, Philippe

doi:10.1016/j.jcmg.2012.10.015

Cited by 185 publications

(111 citation statements)

References 6 publications

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“…However, cut points for determining truly severe AS based on a change in AVA and gradient with pharmacological intervention are not uniform across studies and require further investigation. 15,16 Even so, the current data provide further support for the concept that systemic HTN can influence the evaluation of AS severity. …”

supporting

confidence: 64%

Time to Treat Hypertension in Patients With Aortic Stenosis

Lindman

Otto

2013

Circulation

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Somewhat analogous to the use of dobutamine to clarify pseudo versus truly severe AS in patients with a small AVA, low gradient, and a preserved EF, 15 they demonstrate that nitroprusside can increase flow and provide insight into the true severity of the AS. However, cut points for determining truly severe AS based on a change in AVA and gradient with pharmacological intervention are not uniform across studies and require further investigation. 15,16 Even so, the current data provide further support for the concept that systemic HTN can influence the evaluation of AS severity. 17 Clinical ImplicationsIn managing patients with AS, it is important to recognize the high prevalence of coexistent systemic HTN, its harmful effects on LV remodeling and function, and its adverse impact on clinical outcomes. Moreover, when determining the severity of AS and making decisions about the timing of valve replacement, it is important to recognize that systemic HTN can influence the assessment of AS severity (generally causing overestimation of severity; Figure).17 After valve replacement is performed, there may be a greater tendency toward systemic HTN because of the increased flow from the relief of valvular afterload, which may mitigate the expected favorable effects of LV unloading with valve replacement and limit symptomatic improvement. For all these reasons, both before and after valve replacement, treatment of systemic HTN should be an important objective of medical therapy.When managing a symptomatic patient with uncontrolled systemic HTN (at the time of the echocardiogram) and a small AVA, low gradient, and preserved EF, it is reasonable to redo the echocardiogram when the patient is normotensive, particularly if the measurements of AS severity are borderline between moderate and severe. It also is prudent to reassess symptoms once the patient is consistently normotensive. When managing an asymptomatic patient with uncontrolled systemic HTN and a small AVA, low gradient, and preserved EF, effective HTN treatment may mitigate the deleterious effects on the LV of increased systemic vascular load and potentially delay symptom onset. Although LV outflow obstruction at the level of the valve is the sine qua non of AS, increased systemic vascular load-identified most readily as systemic HTN-is often coexistent with AS and contributes to the pressure overload, hypertrophic remodeling, and dysfunction of the LV, which underlies much of the morbidity and mortality of the disease. As such, we must remember to treat the patient (including HTN and other cardiovascular comorbidities) and not have a myopic focus on the valve alone to provide the best clinical outcomes. Sources of FundingDr Lindman was supported by K23 HL116660 from the NIH. DisclosuresNone. References

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supporting

confidence: 64%

Time to Treat Hypertension in Patients With Aortic Stenosis

Lindman

Otto

2013

Circulation

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“…Thus, we were not able to estimate contractile reserve, which is known to affect the outcome of patients with cLF‐LG 31. Only little is known about the role of dobutamine stress echocardiography in pLF‐LG 33. The assessment of calcium score has gained increasing importance in the diagnosis of LF‐LG because the degree of valve calcification by computed tomography is related to AS severity and outcome.…”

Section: Discussionmentioning

confidence: 98%

Predictors of Mortality and Symptomatic Outcome of Patients With Low‐Flow Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

Stachel

Woitek

Haußig

et al. 2018

JAHA

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BackgroundImpaired left ventricular (LV) ejection fraction is a common finding in patients with aortic stenosis and serves as a predictor of morbidity and mortality after transcatheter aortic valve replacement. However, conflicting data on the most accurate measure for LV function exist. We wanted to examine the impact of LV ejection fraction, mean pressure gradient, and stroke volume index on the outcome of patients treated by transcatheter aortic valve replacement.Methods and ResultsPatients treated by transcatheter aortic valve replacement were primarily separated into normal flow (NF; stroke volume index >35 mL/m2) and low flow (LF; stroke volume index ≤35 mL/m2). Afterwards, patients were divided into 5 groups: “NF–high gradient,” “NF–low gradient” (NF‐LG), “LF–high gradient,” “paradoxical LF‐LG,” and “classic LF‐LG.” The 3‐year mortality was the primary end point. Of 1600 patients, 789 (49.3%) were diagnosed as having LF, which was characterized by a higher 30‐day (P=0.041) and 3‐year (P<0.001) mortality. LF was an independent predictor of all‐cause (hazard ratio, 1.29; 95% confidence interval, 1.03–1.62; P=0.03) and cardiovascular (hazard ratio, 1.37; 95% confidence interval, 1.06–1.77; P=0.016) mortality. Neither mean pressure gradient nor LV ejection fraction was an independent predictor of mortality. Patients with paradoxical LF‐LG (35.0%), classic LF‐LG (35.1%) and LF–high gradient (38.1%) had higher all‐cause mortality at 3 years compared with NF–high gradient (24.8%) and NF‐LG (27.9%) (P=0.001). However, surviving patients showed a similar improvement in symptoms regardless of aortic stenosis entity.Conclusions LF is a common finding within the aortic stenosis population and, in contrast to LV ejection fraction or mean pressure gradient, an independent predictor of all‐cause and cardiovascular mortality. Despite increased long‐term mortality, high procedural success and excellent functional improvement support transcatheter aortic valve replacement in patients with LF severe aortic stenosis.

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“…Clavel et al reported a validation study of dobutamine stress echocardiography for LFLPG severe AS with preserved LVEF, and revealed that approximately 30% of LFLPG severe AS patients had pseudo-severe AS, and therefore a good prognosis, though the authors did not clarify the characteristics or entities of pseudo-severe AS. 9 Complicating conditions may contribute to the clinical relevance of pseudosevere AS in LFLPG severe AS with normal LVEF; reduced SV with small LV size, measurement errors in estimating LV SV or AVA, conditions during echocardiographic examinations, or inconsistencies in the definition of severe AS in current guidelines. 20, 21 In the present study, there was no difference between LFLPG severe AS with preserved GLS and impaired GLS in the prevalence of comorbid CAD or prior MI and CABG, which may affect intrinsic myocardial function.…”

Section: Discussionmentioning

confidence: 99%