Low Gradient“Severe”Aortic Stenosis with Preserved Left Ventricular Ejection Fraction_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

OzkanAlper

Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA;

Corresponding author：

Keywords：

Aortic valve area; Maximal velocity; Transvalvular gradients; Aortic stenosis

DOI：

10.7507/1007-4848.20150181

Video：

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In developed nations, aortic stenosis (AS) is the most common valvular heart disease presentation, and its prevalence is increasing due to aging populations. Accurate diagnosis of the disease process and determination of its severity are essential in clinical decision-making. Although current guidelines recommend measuring transvalvular gradients, maximal velocity, and aortic valve area in determining the disease severity, inconsistent grading of disease severity remains a common problem in clinical practice. Recent studies suggest that patients with paradoxical low-flow and/or low-gradient, severe AS are at a more advanced stage of the disease process and have a poorer prognosis. This mode of presentation may lead to an underevaluation of symptoms and inappropriate delay of AVR. Therefore, this challenging clinical situation should be carefully assessed in particular in symptomatic patients and clinical decisions should be tailored individually.

Citation： OzkanAlper. Low Gradient“Severe”Aortic Stenosis with Preserved Left Ventricular Ejection Fraction. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2015, 22(8): 719-724. doi: 10.7507/1007-4848.20150181 Copy

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5.	Hachicha Z, Dumesnil JG, Bogaty P, et al. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation, 2007, 115:2856-2864.
6.	Christensen KL, Ivarsen HR, Thuesen L, et al. Aortic valve stenosis:fatal natural history despite normal left ventricular function and low invasive peak-to-peak pressure gradients. Cardiology, 2004, 102:147-151.
7.	Jander N, Minners J, Holme I, et al. Outcome of patients with lowgradient "severe" aortic stenosis and preserved ejection fraction. Circulation, 2011, 123:887-895.
8.	Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med, 2000, 343:611-617.
9.	Lindblom D, Lindblom U, Qvist J, et al. Long-term relative survival rates after heart valve replacement. J Am Coll Cardiol, 1990, 15:566-573.
10.	Aurigemma GP, Silver KH, Priest MA, et al. Geometric changes allow normal ejection fraction despite depressed myocardial shortening in hypertensive left ventricular hypertrophy. J Am Coll Cardiol, 1995, 26:195-202.
11.	Ballo P, Mondillo S, Motto A, et al. Left ventricular midwall mechanics in subjects with aortic stenosis and normal systolic chamber function. J Heart Valve Dis, 2006, 15:639-650.
12.	Pibarot P, Dumesnil JG. Aortic stenosis:look globally, think globally. JACC Cardiovasc Imaging, 2009, 2:400-403.
13.	Linhartová K, Filipovský J, Cerbák R, et al. Severe aortic stenosis and its association with hypertension:analysis of clinical and echocardiographic parameters. Blood Press, 2007,16:122-128.
14.	Pagé A, Dumesnil JG, Clavel MA, et al. Metabolic syndrome is associated with more pronounced impairment of left ventricle geometry and function in patients with calcific aortic stenosis:a substudy of the ASTRONOMER (Aortic Stenosis Progression Observation Measuring Effects of Rosuvastatin). J Am Coll Cardiol, 2010, 55:1867-1874.
15.	Briand M, Dumesnil JG, Kadem L, et al. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis:implications for diagnosis and treatment. J Am Coll Cardiol, 2005, 46:291-298.
16.	Hachicha Z, Dumesnil JG, Pibarot P. Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis. J Am Coll Cardiol, 2009, 54:1003-1011.
17.	Cramariuc D, Cioffi G, Rieck AE, et al. Low-flow aortic stenosis in asymptomatic patients:valvular-arterial impedance and systolic function from the SEAS Substudy. JACC Cardiovasc Imaging, 2009, 2:390-399.
18.	Weidemann F, Herrmann S, Störk S, et al. Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis. Circulation, 2009, 120:577-584.
19.	Herrmann S, Störk S, Niemann M, et al. Low-gradient aortic valve stenosis myocardial fibrosis and its influence on function and outcome. J Am Coll Cardiol, 2011, 58:402-412.
20.	Takeda S, Rimington H, Smeeton N, et al. Long axis excursion in aortic stenosis. Heart, 2001, 86:52-56.
21.	Giorgi D, Di Bello V, Talini E, et al. Myocardial function in severe aortic stenosis before and after aortic valve replacement:a Doppler tissue imaging study. J Am Soc Echocardiogr, 2005, 18:8-14.
22.	Delgado V, Tops LF, van Bommel RJ, et al. Strain analysis in patients with severe aortic stenosis and preserved left ventricular ejection fraction undergoing surgical valve replacement. Eur Heart J, 2009, 30:3037-3047.
23.	Ozkan A, Kapadia S, Tuzcu M, et al. Assessment of left ventricular function in aortic stenosis. Nat Rev Cardiol, 2011, 8:494-501.
24.	Lee SP, Kim YJ, Kim JH, et al. Deterioration of myocardial function in paradoxical low-flow severe aortic stenosis:two-dimensional strain analysis. J Am Soc Echocardiogr, 2011, 24:976-983.
25.	Carabello BA. Clinical practice. Aortic stenosis. N Engl J Med, 2002, 346:677-682.
26.	O'Brien B, Schoenhagen P, Kapadia SR, et al. Integration of 3D imaging data in the assessment of aortic stenosis:impact on classification of disease severity. Circ Cardiovasc Imaging, 2011, 4:566-573.

1. American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease):developed in collaboration with the Society of Cardiovascular Anesthesiologists:endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation, 2006, 114:e84-231.
2. Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease:The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J, 2007, 28:230-268.
3. Minners J, Allgeier M, Gohlke-Baerwolf C, et al. Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis. Eur Heart J, 2008, 29:1043-1048.
4. Barasch E, Fan D, Chukwu EO, et al. Severe isolated aortic stenosis with normal left ventricular systolic function and low transvalvular gradients:pathophysiologic and prognostic insights. J Heart Valve Dis, 2008, 17:81-88.
5. Hachicha Z, Dumesnil JG, Bogaty P, et al. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation, 2007, 115:2856-2864.
6. Christensen KL, Ivarsen HR, Thuesen L, et al. Aortic valve stenosis:fatal natural history despite normal left ventricular function and low invasive peak-to-peak pressure gradients. Cardiology, 2004, 102:147-151.
7. Jander N, Minners J, Holme I, et al. Outcome of patients with lowgradient "severe" aortic stenosis and preserved ejection fraction. Circulation, 2011, 123:887-895.
8. Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med, 2000, 343:611-617.
9. Lindblom D, Lindblom U, Qvist J, et al. Long-term relative survival rates after heart valve replacement. J Am Coll Cardiol, 1990, 15:566-573.
10. Aurigemma GP, Silver KH, Priest MA, et al. Geometric changes allow normal ejection fraction despite depressed myocardial shortening in hypertensive left ventricular hypertrophy. J Am Coll Cardiol, 1995, 26:195-202.
11. Ballo P, Mondillo S, Motto A, et al. Left ventricular midwall mechanics in subjects with aortic stenosis and normal systolic chamber function. J Heart Valve Dis, 2006, 15:639-650.
12. Pibarot P, Dumesnil JG. Aortic stenosis:look globally, think globally. JACC Cardiovasc Imaging, 2009, 2:400-403.
13. Linhartová K, Filipovský J, Cerbák R, et al. Severe aortic stenosis and its association with hypertension:analysis of clinical and echocardiographic parameters. Blood Press, 2007,16:122-128.
14. Pagé A, Dumesnil JG, Clavel MA, et al. Metabolic syndrome is associated with more pronounced impairment of left ventricle geometry and function in patients with calcific aortic stenosis:a substudy of the ASTRONOMER (Aortic Stenosis Progression Observation Measuring Effects of Rosuvastatin). J Am Coll Cardiol, 2010, 55:1867-1874.
15. Briand M, Dumesnil JG, Kadem L, et al. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis:implications for diagnosis and treatment. J Am Coll Cardiol, 2005, 46:291-298.
16. Hachicha Z, Dumesnil JG, Pibarot P. Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis. J Am Coll Cardiol, 2009, 54:1003-1011.
17. Cramariuc D, Cioffi G, Rieck AE, et al. Low-flow aortic stenosis in asymptomatic patients:valvular-arterial impedance and systolic function from the SEAS Substudy. JACC Cardiovasc Imaging, 2009, 2:390-399.
18. Weidemann F, Herrmann S, Störk S, et al. Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis. Circulation, 2009, 120:577-584.
19. Herrmann S, Störk S, Niemann M, et al. Low-gradient aortic valve stenosis myocardial fibrosis and its influence on function and outcome. J Am Coll Cardiol, 2011, 58:402-412.
20. Takeda S, Rimington H, Smeeton N, et al. Long axis excursion in aortic stenosis. Heart, 2001, 86:52-56.
21. Giorgi D, Di Bello V, Talini E, et al. Myocardial function in severe aortic stenosis before and after aortic valve replacement:a Doppler tissue imaging study. J Am Soc Echocardiogr, 2005, 18:8-14.
22. Delgado V, Tops LF, van Bommel RJ, et al. Strain analysis in patients with severe aortic stenosis and preserved left ventricular ejection fraction undergoing surgical valve replacement. Eur Heart J, 2009, 30:3037-3047.
23. Ozkan A, Kapadia S, Tuzcu M, et al. Assessment of left ventricular function in aortic stenosis. Nat Rev Cardiol, 2011, 8:494-501.
24. Lee SP, Kim YJ, Kim JH, et al. Deterioration of myocardial function in paradoxical low-flow severe aortic stenosis:two-dimensional strain analysis. J Am Soc Echocardiogr, 2011, 24:976-983.
25. Carabello BA. Clinical practice. Aortic stenosis. N Engl J Med, 2002, 346:677-682.
26. O'Brien B, Schoenhagen P, Kapadia SR, et al. Integration of 3D imaging data in the assessment of aortic stenosis:impact on classification of disease severity. Circ Cardiovasc Imaging, 2011, 4:566-573.

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Low Gradient“Severe”Aortic Stenosis with Preserved Left Ventricular Ejection Fraction

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