Paradoxical low-flow, low-gradient aortic stenosis despite preserved left ventricular ejection fraction: new insights from weights of operatively excised aortic valves

被引:37
作者
Clavel, Marie-Annick [1 ]
Cote, Nancy [2 ]
Mathieu, Patrick [2 ]
Dumesnil, Jean G. [1 ]
Audet, Audrey [2 ]
Pepin, Andree [2 ]
Couture, Christian [3 ]
Fournier, Dominique [2 ]
Trahan, Sylvain [3 ]
Page, Sylvain [3 ]
Pibarot, Philippe [1 ]
机构
[1] Univ Laval, Inst Univ Cardiol & Pneumol Quebec, Dept Cardiol, Quebec Heart & Lung Inst, Ste Foy, PQ G1V 4G5, Canada
[2] Univ Laval, Inst Univ Cardiol & Pneumol Quebec, Dept Cardiac Surg, Quebec Heart & Lung Inst, Ste Foy, PQ G1V 4G5, Canada
[3] Univ Laval, Inst Univ Cardiol & Pneumol Quebec, Dept Pathol, Quebec Heart & Lung Inst, Ste Foy, PQ G1V 4G5, Canada
基金
加拿大健康研究院;
关键词
Aortic stenosis; Low flow; Echocardiography; Surgery; REPLACEMENT; ECHOCARDIOGRAPHY; SEVERITY; IMPACT;
D O I
10.1093/eurheartj/ehu152
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Aims We reported that patients with small aortic valve area (AVA) and low flow despite preserved left ventricular ejection fraction (LVEF), i.e. 'paradoxical' low flow (PLF), have worse outcomes compared with patients with normal flow (NF), although they generally have a lower mean gradient (MG). The aortic valve weight (AVW) excised at the time of valve replacement is a flow-independent marker of stenosis severity. The objective of this study was to compare the AVW of patients with PLF and MG<40 mmHg with the AVW of patients with NF and MG >= 40 mmHg. Methods and results We recruited 250 consecutive patients undergoing valve replacement (Cohort A) for severe stenosis. Among them, 33 (13%) were in PLF [LVEF > 50% but stroke volume index (SVi) <= 35 mL/m(2)] with MG < 40 mmHg (PLF-LG group) and 105 (42%) were in NF (LVEF > 50% and SVi > 35 mL/m(2)) with MG >= 40 mmHg (NF-HG group). Despite a much lower MG (29 +/- 7 vs. 53 +/- 10 mmHg; P < 0.0001), patients in the PLF-LG group had a similar AVA (0.73 +/- 0.12 vs. 0.69 +/- 0.13; P = 0.19) compared with those in the NF-HG group. The AVW [median (interquartile): 1.90 (1.63-2.50) vs. 2.60 (1.66-3.32)] and prevalence of bicuspid phenotype (15 vs. 42%) were lower in the PLF-LG group than in the NF-HGgroup. However, AVWs analysed separately in the tricuspid and bicuspid valves were similar in both groups [tricuspid valves: 1.80 (1.63-2.50) vs. 2.30 (1.58-3.00) g; P = 0.26 and bicuspid valves: 2.72 (1.73-3.61) vs. 2.60 (2.10-3.55) g; P = 0.93]. When using cut-point values of AVW established in another series of non-consecutive patients (n = 150, Cohort B) with NF and concordant Doppler-echocardiographic findings, we found that the percentage of patients with evidence of severe stenosis in Cohort A was 70% in patients with PLF-LG and 86% in patients with NF-HG. Conclusion The aortic valve weight data reported in this study provide evidence that a large proportion of patients with PLF and low-gradient have a severe stenosis and that the gradient may substantially underestimate stenosis severity in these patients. A multi-parametric approach including all Doppler-echocardiographic parameters of valve function as well as other complementary diagnostic tests may help correctly identify these patients.
引用
收藏
页码:2655 / 2662
页数:8
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  • [11] Systemic Hypertension in Low-Gradient Severe Aortic Stenosis With Preserved Ejection Fraction
    Eleid, Mackram F.
    Nishimura, Rick A.
    Sorajja, Paul
    Borlaug, Barry A.
    [J]. CIRCULATION, 2013, 128 (12) : 1349 - 1353
  • [12] Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival
    Hachicha, Zeineb
    Dumesnil, Jean G.
    Bogaty, Peter
    Pibarot, Philippe
    [J]. CIRCULATION, 2007, 115 (22) : 2856 - 2864
  • [13] Low-Gradient Aortic Valve Stenosis Myocardial Fibrosis and Its Influence on Function and Outcome
    Herrmann, Sebastian
    Stoerk, Stefan
    Niemann, Markus
    Lange, Volkmar
    Strotmann, Joerg M.
    Frantz, Stefan
    Beer, Meinrad
    Gattenloehner, Stefan
    Voelker, Wolfram
    Ertl, Georg
    Weidemann, Frank
    [J]. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 2011, 58 (04) : 402 - 412
  • [14] Outcome of Patients With Low-Gradient "Severe" Aortic Stenosis and Preserved Ejection Fraction
    Jander, Nikolaus
    Minners, Jan
    Holme, Ingar
    Gerdts, Eva
    Boman, Kurt
    Brudi, Philippe
    Chambers, John B.
    Egstrup, Kenneth
    Kesaniemi, Y. Antero
    Malbecq, William
    Nienaber, Christoph A.
    Ray, Simon
    Rossebo, Anne
    Pedersen, Terje R.
    Skjaerpe, Terje
    Willenheimer, Ronnie
    Wachtell, Kristian
    Neumann, Franz-Josef
    Gohlke-Baerwolf, Christa
    [J]. CIRCULATION, 2011, 123 (08) : 887 - 895
  • [15] Clinical Outcome in Asymptomatic Severe Aortic Stenosis Insights From the New Proposed Aortic Stenosis Grading Classification
    Lancellotti, Patrizio
    Magne, Julien
    Donal, Erwan
    Davin, Laurent
    O'Connor, Kim
    Rosca, Monica
    Szymanski, Catherine
    Cosyns, Bernard
    Pierard, Luc A.
    [J]. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 2012, 59 (03) : 235 - 243
  • [16] Aortic valve stenosis in community medical practice: Determinants of outcome and implications for aortic valve replacement
    Malouf, Joseph
    Le Tourneau, Thierry
    Pellikka, Patricia
    Sundt, Thoralf M.
    Scott, Christopher
    Schaff, Hartzell V.
    Enriquez-Sarano, Maurice
    [J]. JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY, 2012, 144 (06) : 1421 - 1427
  • [17] Differential left ventricular remodelling and longitudinal function distinguishes low flow from normal-flow preserved ejection fraction low-gradient severe aortic stenosis
    Mehrotra, Praveen
    Jansen, Katrijn
    Flynn, Aidan W.
    Tan, Timothy C.
    Elmariah, Sammy
    Picard, Michael H.
    Hung, Judy
    [J]. EUROPEAN HEART JOURNAL, 2013, 34 (25) : 1906 - 1914
  • [18] Outcome and Impact of Surgery in Paradoxical Low-Flow, Low-Gradient Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction A Cardiac Catheterization Study
    Mohty, Dania
    Magne, Julien
    Deltreuil, Mathieu
    Aboyans, Victor
    Echahidi, Najmeddine
    Cassat, Claude
    Pibarot, Philippe
    Laskar, Marc
    Virot, Patrice
    [J]. CIRCULATION, 2013, 128 (11) : S235 - S242
  • [19] Impact of Aortic Valve Replacement on Outcome of Symptomatic Patients With Severe Aortic Stenosis With Low Gradient and Preserved Left Ventricular Ejection Fraction
    Ozkan, Alper
    Hachamovitch, Rory
    Kapadia, Samir R.
    Tuzcu, E. Murat
    Marwick, Thomas H.
    [J]. CIRCULATION, 2013, 128 (06) : 622 - 631
  • [20] Survival Benefit of Aortic Valve Replacement in Patients With Severe Aortic Stenosis With Low Ejection Fraction And Low Gradient With Normal Ejection Fraction
    Pai, Ramdas G.
    Varadarajan, Padmini
    Razzouk, Anees
    [J]. ANNALS OF THORACIC SURGERY, 2008, 86 (06) : 1781 - 1790