Low gradient, low ejection fraction aortic stenosis

Low gradient aortic stenosis can be caused by critical aortic stenosis causing left ventricular impairment or by more moderate aortic stenosis coexisting with another cause of left ventricular impairment. The main challenges are to differentiate these two states and then to determine whether the left ventricle is likely to recover after aortic valve surgery. Exhaustive echocardiography is necessary, including the use of dobutamine stress. Guideline criteria for severe aortic stenosis are given in this article. The most secure criteria are mean transaortic pressure difference greater than 30 mm Hg and effective orifice area less than 1.2 cm2 during dobutamine stress. However, the presence of left ventricular contractile reserve more closely determines outcome after surgery than do markers of stenosis. Surgery is most clearly indicated if there is severe aortic stenosis and an increase in the systolic velocity integral by greater than 20% during dobutamine infusion. Preoperative catheterization is necessary to determine coronary anatomy, but the aortic valve should not be crossed because of the relatively high risk of death, stroke, pulmonary edema, and cardiogenic shock. In patients judged too ill for immediate surgery, a period of medical resuscitation with diuretics and dobutamine should be considered. Balloon valvotomy is not indicated.