Management of paradoxical low-flow, low-gradient aortic stenosis : need for an integrated approach, including assessment of symptoms, hypertension, and stenosis severity

Authors: Pibarot, PhilippeClavel, Marie-Annick
Abstract: In 2007, we reported that a substantial proportion of patients with severe aortic stenosis may have a low flow (LF) (i.e., reduced stroke volume), and thus, often have a low transvalvular pressure gradient (LG), despite a preserved left ventricular ejection fraction (LVEF) (1). The 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines (2) classified this “paradoxical” LF/LG entity as a D3 stage of aortic stenosis, which is defined as an aortic valve area (AVA) of <1.0 cm2, an indexed AVA of <0.6 cm2/m2, a mean gradient of <40 mm Hg, a LVEF of >50%, and a stroke volume index (SVi) of <35 ml/m2. Previous studies 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 reported that patients with paradoxical LF/LG aortic stenosis have worse outcomes than patients with moderate aortic stenosis or with severe aortic stenosis and a high-gradient (HG) and that their outcomes improve with aortic valve replacement (AVR). Accordingly, the 2014 ACC/AHA guidelines included a Class IIa (Level of Evidence: C) recommendation for AVR in these patients: “AVR is reasonable in symptomatic patients who have low-flow, low-gradient severe AS who are normotensive and have a LVEF =50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms” (2). The main findings of the retrospective study by Tribouilloy et al. (14) published in this issue of the Journal were: 1) patients with LF/LG and preserved LVEF have similar outcomes as patients with moderate aortic stenosis or with severe aortic stenosis and a HG; and 2) AVR does not improve these patients’ outcomes. The investigators should be commended for providing important data on the challenging subset of patients with paradoxical LF/LG aortic stenosis.
Document Type: Article de recherche
Issue Date: 6 January 2015
Open Access Date: 27 July 2016
Document version: VoR
This document was published in: Journal of the American College of Cardiology, Vol. 65 (1), 67–71 (2015)
Elsevier Biomedical
Alternative version: 10.1016/j.jacc.2014.10.030
Collection:Articles publiés dans des revues avec comité de lecture

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