scholarly journals Interaction of stroke volume and myocardial phenotype in patients with severe aortic stenosis referred for intervention: outcome data from the BSCMR AS700 study

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
GD Thornton ◽  
TA Musa ◽  
M Rigolli ◽  
M Loudon ◽  
C Chin ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Stroke Volume ◽  
Cardiovascular Mortality ◽  
Left Atrial Volume ◽  
Left Ventricular ◽  
Low Flow ◽  
Aortic Valve Area ◽  
Mortality Hazard ◽  
Myocardial Remodelling

Abstract Funding Acknowledgements Type of funding sources: None. onbehalf The BSCMR Valve Consortium Background  Patients with low-flow aortic stenosis (LF-AS) have higher mortality than those with high-flow severe AS.  The conventional echocardiographic definition of LF-AS is an indexed stroke volume (SVi) <35ml/m2. Whether this cut-off translates to cardiac magnetic resonance (CMR), and how CMR SVi associates with myocardial remodelling (volume/function/scar) and survival is unclear. Purpose  To determine the association between CMR SVi, myocardial remodelling and survival in severe symptomatic AS.  Methods   In a multi-centre longitudinal outcome study of patients with severe AS listed for either surgical (SAVR) or transcatheter aortic valve intervention (TAVI) at six cardiothoracic centres, survival was assessed and stratified by SVi. Patients underwent preprocedural echocardiography and CMR between January 2003 and May 2015.  Standardised core-lab analyses on pre-procedural CMR for biventricular volumes, function and scar quantification were performed. All-cause and cardiovascular mortality were tracked for a minimum of two years after AVR. Results  A total of 674 patients with severe AS (age 75 ± 14years; 63% male, aortic valve area 0.4 ± 0.1 cm2/m2) were included.  Patients with low SVi by CMR <35ml/m2 were older and had a greater burden of comorbidities (atrial fibrillation [AF], diabetes, high BMI). Independent predictors of SVi were age, AF, increased left atrial volume, aortic valve regurgitant fraction and left ventricular mass (LV) mass index (by CMR). There was no difference in SVi with choice of intervention (TAVI vs SAVR) or presence of late gadolinium enhancement. In multivariate analysis (Table 1), SVi was associated with cardiovascular mortality in the whole cohort (HR 0.97, 95%CI 0.95-0.99, p = 0.02), and all-cause mortality after TAVI (HR 0.97, 95%CI 0.95-0.99, p = 0.006) but not SAVR (p = 0.6). Adjusted mortality hazard increases below 50ml/m2 and plateaus between 35-40ml/m2 (Figure 1A), adjusted for LGE, STS score (Society of Thoracic Surgery score) and wall thickness. Conclusion SVi by CMR is an independent predictor of cardiovascular mortality. Mortality hazard increases progressively below a SVi of 50mL/m2. Abstract Figure 1

P3369Impact of global left ventricular afterload, aortic stenosis severity and left ventricular hypertrophy on global myocardial work

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F Ilardi ◽  
S Marchetta ◽  
R E Dulgheru ◽  
S Cimino ◽  
G D'Amico ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Stroke Volume ◽  
Speckle Tracking ◽  
Left Ventricular ◽  
Low Flow ◽  
Control Group ◽  
Aortic Valve Area ◽  
Global Work ◽  
Valve Area

Abstract Background Myocardial work (MW) is an innovative tool, that derives from myocardial strain with the advantage to incorporate measurement of deformation and load. Therefore, it could be useful in conditions of increased afterload, such as aortic stenosis (AS). To date, little is known about the changes in MW related to AS severity, left ventricle (LV) geometry and arterial compliance. Purpose We investigated the effect of valvulo-arterial impedance (Zva), stroke volume and LV hypertrophy in patients with AS and preserved LV ejection fraction (EF). Methods We retrospectively analyzed 283 patients (60% males, mean age 71±12 years old) with AS (aortic valve area ≤1.5 cm2) and LVEF≥50%. Exclusion criteria were more than mild associated cardiac valve lesion, left bundle branch block, and suboptimal quality of speckle-tracking image analysis. The control group included 50 patients matched for age and sex. Clinical, demographic and resting echocardiographic data were recorded, including quantification of 2D global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE). Results Patients with AS had higher systolic (p=0.017) and diastolic arterial pressure (p=0.007), increased LV wall thickness, mass index (p<0.001) and volumes (p=0.045) compared to controls. Greater indexed left atrial volume, E/e' and trans-tricuspid gradient were also observed in the AS group (p<0.001). As expected, speckle tracking analysis revealed significant lower GLS in AS than in control group (18.7±3.2 vs 20.7±2.1%, p<0.001). Conversely, increased values of GCW and GWI (respectively 2965±647 vs 2360±353 mmHg%, and 2535±559 vs 2005±302 mmHg%, p<0.001) were observed in patients with AS. Besides, GWW was significantly increased in AS vs controls (147±108 vs 90±49 mmHg%, p=0.001), with no changes in terms of GWE (95±4 vs 96±2%, p=0.110). When patients were stratified according to the AS severity, the analysis of variance revealed that GCW, GWI and GWW significantly increased with higher transaortic mean gradient and lower aortic valve area (p<0.001). Also Zva demonstrated to impact on CGW (p=0.040) and GWW (p<0.001), with increased values in presence of increased global LV afterload (Zva>4.5 mmHg/ml/m2). Conversely, patients with low-flow AS (stroke volume index <35 ml/m2) showed lowers values of GCW (p=0.014) and GWI (p=0.001) compared to normal flow AS, but increased GWW (p=0.041) and reduced GWE (93±7 vs 95±4%, p=0.010). Finally, LV geometry didn't influence significantly GCW and GWE, only an increase of GWW was observed in patients with eccentric hypertrophy (p=0.031). Conclusion In patients with AS and preserved LVEF, GLS reduction is accompanied by an increase of GCW, GWI and GWW, without affecting the GWE. These modifications seem to be correlated to the severity of AS, low-flow state and increased global LV afterload but not on the grade of LV hypertrophy.

scholarly journals Aortic valve area, stroke volume,left ventricular hypertrophy, remodeling and fibrosis in aortic stenosis assessed by cardiac MRI

2013 ◽  
Vol 34 (suppl 1) ◽  
pp. P277-P277
Author(s):  
G. Barone-Rochette ◽  
S. Pierard ◽  
S. Seldrum ◽  
C. De Meester De Ravensteen ◽  
J. Melchior ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Left Ventricular Hypertrophy ◽  
Aortic Stenosis ◽  
Stroke Volume ◽  
Cardiac Mri ◽  
Ventricular Hypertrophy ◽  
Left Ventricular ◽  
Aortic Valve Area ◽  
Valve Area

High Prevalence of Severe Aortic Stenosis in Low-Flow State Associated With Atrial Fibrillation

2021 ◽  
Author(s):  
Said Alsidawi ◽  
Sana Khan ◽  
Sorin V. Pislaru ◽  
Jeremy J. Thaden ◽  
Edward A. El-Am ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Left Ventricular ◽  
Hazard Ratio ◽  
Low Flow ◽  
Left Ventricular Ejection ◽  
Aortic Valve Area ◽  
Flow State ◽  
Ventricular Ejection Fraction

Background: Atrial fibrillation (AF) is a low-flow state and may underestimate aortic stenosis (AS) severity. Single-high Doppler signals (HS) consistent with severe AS (peak velocity ≥4 m/s or mean gradient ≥40 mm Hg) are averaged down in current practice. The objective for the study was to determine the significance of HS in AF low-gradient AS (LGAS). Methods: One thousand five hundred forty-one patients with aortic valve area ≤1 cm 2 and left ventricular ejection fraction ≥50% were identified and classified as high-gradient AS (HGAS) (≥40 mm Hg) and LGAS (<40 mm Hg), and AF versus sinus rhythm (SR). Available computed tomography aortic valve calcium scores (AVCS) were retrieved from the medical record. Outcomes were assessed. Results: Mean age was 76±11 years, female 47%. Mean gradient was 51±12 in SR-HGAS, 48±10 in AF-HGAS, 31±5 in SR-LGAS, and 29±7 mm Hg in AF-LGAS, all P ≤0.001 versus SR-HGAS; HS were present in 33% of AF-LGAS. AVCS were available in 34%. Compared with SR-HGAS (2409 arbitrary units; interquartile range, 1581–3462) AVCS were higher in AF-HGAS (2991 arbitrary units; IQR1978–4229, P =0.001), not different in AF-LGAS (2399 arbitrary units; IQR1817–2810, P =0.47), and lower in SR-LGAS (1593 arbitrary units; IQR945–1832, P <0.001); AVCS in AF-LGAS were higher when HS were present ( P =0.048). Compared with SR-HGAS, the age-, sex-, comorbidity index-, and time-dependent aortic valve replacement-adjusted mortality risk was higher in AF-HGAS (hazard ratio=1.82 [1.40–2.36], P <0.001) and AF-LGAS with HS (hazard ratio=1.54 [1.04–2.26], P =0.03) but not different in AF-LGAS without HS or SR-LGAS (both P =not significant). Conclusions: Severe AS was common in AF-LGAS. AVCS in AF-LGAS were not different from SR-HGAS. AVCS were higher and mortality worse in AF-LGAS when HS were present.

scholarly journals P289 Aortic valve resistance risk-stratifies low-gradient aortic stenosis

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
J Cho ◽  
T Uejima ◽  
H Nishikawa ◽  
J Yajima ◽  
T Yamashita
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Stroke Volume ◽  
Clinical Decision Making ◽  
Stroke Volume Index ◽  
Low Flow ◽  
Volume Index ◽  
Aortic Valve Area ◽  
Event Free Survival ◽  
Free Survival

Abstract Background Grading the severity of aortic stenosis (AS) is challenging, since there is a discrepancy between aortic valve area (AVA) and mean pressure gradient (mPG). Arotic valve resistance (RES) has been proposed as a usuful descriptor of AS severity, but it is not commonly used for clinical decision-making, because its robust validation of clinical-outcome efficacy is lacking. This study aimed to investigate whether RES holds an incremental value for risk-stratifying AS. Methods This study recuited 565 AS patients (AVA &lt; 1.5cm²) referred to echocardiography for valve assessment. The patients were divided into three different groups, according to the guidelines: high-gradient AS (HG-AS, mPG≥40mmHg, n = 157), low-gradient AS (LG-AS, mPG &lt; 40mmHg + AVA ≤ 1.0cm², n = 155) and moderate AS (Mod-AS, mPG &lt; 40mmHg + AVA &gt; 1.0cm², n = 253). RES was calculated from Doppler measurement of mPG and stoke volume. The diagnositic cutoff point for RES was determined at 190 dynes × s×cm-5 by substituting AVA = 1.0cm² and mPG = 40mmHg into the definition formula of RES and Gorlin formula. The patients were followed up for 2 years. The endpoint was a composite of cardiac death, hospitalization for heart failure and aortic valve replacement necessitated by the development of AS-related symptoms. Result Kaplan-Meier analyses showed that LG-AS exhibited an intermediate outcome between HG-AS and Mod-AS (event-free survival at 2 years = 20.9% for HG-AS, 59.7% for LG-AS, 89.9% for Mod-AS, p &lt; 0.001, figure A). When LG-AS was stratified by RES, the survival curves showed a significant separation (event-free survival at 2 years = 35.3% for high RES, 70.7% for low RES, p &lt; 0.001, figure B). This trend persisted even when analysed separately for norml (stroke volume index &gt; 35ml/m²) and low (stroke volume index ≤ 35ml/m²) flow state ((normal flow) event-free survival at 2 years = 38.7% for high RES, 70.4% for low RES, p = 0.023, figure C; (low flow) event-free survival at 2 years = 26.7% for high RES, 74.6% for low RES, p &lt; 0.001, figure D). Conclusion This study confirmed the clinical efficacy of RES for risk-stratifying LG-AS patients. Abstract P289 Figure.

scholarly journals P1370 Correlation of aortic stenosis by integrated transthoracic and transesophageal echocardiography with calcium score

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
S Schwartzenberg ◽  
Y Shapira ◽  
M Vaturi ◽  
M Nassar ◽  
A Hamdan ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Stroke Volume Index ◽  
Left Ventricular ◽  
Low Flow ◽  
Volume Index ◽  
Left Ventricular Ejection ◽  
Aortic Valve Area ◽  
Ventricular Ejection Fraction ◽  
Coronary Ct

Abstract Funding Acknowledgements None BACKGROUND Aortic stenosis (AS) classification depends on left-ventricular ejection-fraction (LVEF &lt;≥50%), aortic valve area (AVA&lt;≥1cm2), mean pressure gradient (MG&lt;≥40mmHg), peak velocity&lt;≥400 cm/sec, and stroke-volume index (SVI&lt;≥35ml/m2). Aortic Valve Agatston CT score (AVC) correlates with AS severity by trans-thoracic echo (TTE), but its association with AS severity determined by integrated TTE and TEE is unknown. PURPOSE We investigated correlation of AVC with dichotomous AS grouping by Integrated TTE + TEE vs TTE only. METHODS 64 TAVI candidates underwent sequential TTE and TEE, of which 24 underwent coronary CT within 4 months. Based on recommended conservative vs invasive treatment implication (A/B respectively), AS types were aggregated separately by TTE or Integrated TTE-TEE into two groups: Group-A (Moderate AS and Normal-Flow Low-Gradient), and Group-B (High-Gradient, Low-EF Low-Flow Low-Gradient, and Paradoxical Low-Flow Low-Gradient). Continuous and dichotomous AVC correlation (cutoffs based on guidelines) with echo binary classification was then determined. RESULTS Patients were 81.1(77.3-84.6) years old, 18(48.6%) were women, and had LVEF of 60% (49-65). AVC-score distribution in the two AS A/B Groups by two echo modalities is presented in the boxplot Figure. Only classification by TTE held discriminative accuracy in A/B grouping, with Area-Under-Curve of 0.736 (CI 0.57-0.9), and optimal threshold value of 1946 AU having 77% sensitivity and 74% specificity. Compared with AVC dichotomous classification, integrated TTE + TEE upgraded AS class (from A to B) in 5/6 (83.3%) patients vs 12/18 (66.7%) in which it downgraded AS class from B to A. CONCLUSIONS Aortic valve calcification correlates well with AS class dichotomized by operative implication through conventional TTE but not through integrated TTE + TEE. Our preliminary results appear to be caused by initial selection bias of patients in whom coronary CT performance was deemed to be justified by the treating physician rather than reflect a true better correlation between CT score and AS assessment by TTE vs by integrated TTE + TEE. Abstract P1370 Figure.

scholarly journals Use of passive leg rise as an add-on to dobutamine in patients with paradoxical low-flow, low-gradient aortic stenosis

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
E Buffle ◽  
A Papadis ◽  
C Seiler ◽  
S F De Marchi
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Stroke Volume Index ◽  
Left Ventricular ◽  
Low Flow ◽  
Volume Index ◽  
Aortic Valve Area ◽  
Low Ejection Fraction ◽  
Valve Area

Abstract Background Dobutamine has been proposed for the assessment of low-flow, low-gradient aortic stenosis (LFLGAS). However, in 1/3 of patients, no increase in stroke volume index can be achieved by Dobutamine, thus hampering its diagnostic value. This study evaluated the manoeuvre of cardiac preload augmentation by passive leg rise (PLR) alone or on top of Dobutamine to increase stroke volume index (SVI) in patients with LFLGAS, particularly in paradoxical LFLGAS. Methods We examined 50 patients with LFLGAS. Patients were assigned to the paradoxical LFLGAS (Paradox) group if left ventricular ejection fraction (LVEF) was ≥50% (n=29) and to the LFLGAS with low ejection fraction (LEF) group if LVEF was &lt;50% (n=21). A modified Dobutamine stress echocardiography was performed in all patients with the following 4 steps: Rest, PLR alone, maximal Dobutamine infusion rate alone (Dmax) and Dobutamine plus PLR (Dmax + PLR). Three SVI measurement methods were used: first the left ventricular outflow tract velocity time integral (LVOT VTI) method, second the 2D Simpson's method, and third the 3D method. The corresponding aortic valve area (AVA) was obtained by the continuity equation. The increase of those values compared to measurements at rest was calculated and compared between the 3 stress steps. Results In the paradoxical LFLGAS group, delta SVI with Dmax assessed by both Simpson's (depicted in the figures) and 3D method was lowest compared to PLR and Dmax + PLR. PLR alone yielded an equally high delta SVI as Dmax + PLR in Simpson's and 3D, and was at least as high as Dmax across all methods. Dobutamine alone yielded the lowest delta transaortic aortic valve VTI. The highest delta aortic valve area resulted for Dmax + PLR. In the LEF group, the three stress steps yielded an equally high delta SVI with Simpson's method. Dmax never yielded a higher delta SVI than PLR alone. The yielded delta SVI was the highest for Dmax + PLR for both LVOT VTI and 3d method, although the difference was overall not as strong as in the Paradox group. Conclusions In patients with paradoxical LFLGAS, Dobutamine alone is inadequate for testing the potential of aortic valve opening augmentation. Instead, PLR alone or the addition of PLR plus Dobutamine should be used for that purpose. In low LVEF, adding PLR to Dobutamine also seems useful although its diagnostic added value is less evident than in the Paradox group. FUNDunding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Gottfried und Julia Bangerter-Rhyner-Foundation Paradox group Low ejection fraction group

scholarly journals Left atrial dynamics in the hemodynamic response during exercise in patients with asymptomatic severe aortic stenosis

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
T Sugimoto ◽  
F Bandera ◽  
G Generati ◽  
E Alfonzetti ◽  
M Guazzi
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Left Atrial ◽  
Cardiopulmonary Exercise Testing ◽  
Left Ventricular ◽  
Low Flow ◽  
Volume Index ◽  
Left Ventricular Ejection ◽  
Aortic Valve Area ◽  
Ventricular Ejection Fraction

Abstract Background The hemodynamic impact of left atrial (LA) dynamics in aortic stenosis (AS) in relation to cardiopulmonary response to exercise has never been studied. We aimed at investigating the link between LA function vs hemodynamics and prognosis in asymptomatic severe AS patients. Methods A total of 106 patients: 76 asymptomatic severe AS patients (aortic valve area (AVA) &lt;1.0 cm2 or AVA index &lt;0.6 cm2/m2) and 30 gender-matched control subjects underwent cardiopulmonary exercise testing combined with Echo-Doppler with assessment of LA strain. AS patients were divided into 4 groups according to peak aortic jet velocity (PV), mean pressure gradient (MPG), stroke volume index (SVI), and left ventricular ejection fraction (LVEF). Results Normal-flow low-gradient AS (NFLG: PV &lt;4 m/s and MPG &lt;40 mmHg, SVI &gt;35ml/m2, LVEF ≥50%, N=23), High-gradient AS (HG: PV ≥4 m/s or MPG ≥40 mmHg, LVEF ≥50%, N=23), Paradoxical low-flow low-gradient AS (PLFLG: PV &lt;4 m/s and MPG &lt;40 mmHg, SVI ≤35ml/m2, LVEF ≥50%, N=18), and Classical low-flow AS (CLF: LVEF &lt;50%, N=12) had a higher LA volume index than Control (Control 22±6, NFLG 38±12*, HG 33±9*, PLFLG 33±11*, and CLF 49±15* ml/m2, *P&lt;0.05 vs Control). In PLFLG and NFLG AS, LA strain at rest (21±9 and 26±13%) and during exercise (26±12 and 31±14%) were decreased compared to Control (37±8% at rest, 43±11% during exercise) but LA strain was increased from rest to exercise (P&lt;0.001). HG and CLF AS had no increase in LA strain (31±15 and 19±10% at rest, 28±15 and 18±9% during exercise) (figure). In Cox proportional hazards analysis, age and gender adjusted hazard ratio for the composite end point (aortic valve replacement, hospitalization for heart failure, and all-cause mortality) of changes in LA-strain from rest to exercise (1% increase) was 1.05 (95% CI 1.00 to 1.09, P=0.044) among AS patients. Conclusions In asymptomatic severe AS, the study of LA functional adaptation to exercise plays a key role in the hemodynamic unfavorable cascade signaling major adaptive differences in dynamics during physical challenge. Overall, LA dynamics provides prognostic information also in AS patients. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals P1303 Pseudo-severe aortic stenosis due to mechanical dyssynchrony in a patient with low contractile reserve

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
U Breskvar ◽  
M Mrak ◽  
A Zupan Meznar ◽  
D Zizek
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Stroke Volume ◽  
Stress Echocardiography ◽  
Mechanical Dyssynchrony ◽  
Left Ventricular ◽  
Low Flow ◽  
Cardiac Resynchronization ◽  
Contractile Reserve ◽  
Severe Stenosis

Abstract Introduction Aortic stenosis characterization in patients with low flow – low gradient stenosis (LF-LG) and reduced left ventricular (LV) ejection fraction (EF) is challenging. In this subgroup, pseudo- severe stenosis should be properly identified, as these patients are treated conservatively with heart failure therapy. Its identification relies mainly on preserved contractile reserve seen during dobutamine echocardiography. We present a patient with low contractile reserve and pseudo-severe stenosis due to mechanical dyssynchrony. Case presentation 83-years old patient with ischemic heart disease and chronic kidney disease was admitted to our department due to progressive exertional dyspnea. In 2014 he underwent dual-chamber pacemaker (PM) implantation due to sick sinus syndrome and was programmed to asynchronous pacing mode (VVI mode) in 2016 as atrial electrode dysfunction was observed. Coronary angiogram was normal. Echocardiography showed enlarged left ventricle (LV EDV 180 ml), reduced EF (33%) and signs of mechanical dyssynchrony. Peak aortic valve velocity was 2.5 m/s, mean pressure gradient (MPG) 13 mmHg and AVA 1.0 cm2. Stroke volume was reduced (SVI 28 ml/m2). LF-LG aortic stenosis was suspected. Stress echocardiography using dobutamine at peak infusion of 15 mcg/kg/min showed low contractile reserve (EF 37%, SVI 33 ml/m2) with no significant changes in aortic valve parameters (MPG 29 mmHg, AVA 0.9 cm2). However, significant masurement disparity was noted and at least partly contributed to atrio-ventricular (A-V) and inter-ventricular dyssynchrony because of asynchronous VVI pacing. To overcome A-V and intraventricular dyssynchrony we decided for atrial lead reposition and upgrade to cardiac resynchronization therapy (CRT-P). After six months of CRT, normalization of EF and improvement of exercise capacity were observed. Furthermore, additional evaluation of aortic valve showed only moderate stenosis (peak velocity 2,8 m/s, MPG 18 mmHg and AVA 1.4 cm2). Stroke volume was normal (SVI 48 ml/m2). Consequently, we postponed potential surgical or interventional treatment of the aortic valve. Conclusion Considerable LV mechanical dyssynchrony could interfere with determining the severity of aortic stenosis. As demonstrated in the present case report, special considerations should be taken in patients with notable LV dyssynchrony and low contractile reserve as it may not be overcome with dobutamine stress echocardiography as recommended by the current guidelines.

Abstract 5773: Reduced Left Ventricular Vortex Formation Ability Despite Preserved Ejection Fraction in Low-Flow, Low-Gradient Severe Aortic Stenosis

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Li Ching Lee ◽  
Sher Lynn Lim ◽  
Huay Cheem Tan ◽  
Boon Lock Chia ◽  
Kian Keong Poh
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Severe Aortic Stenosis ◽  
Vortex Formation ◽  
Left Ventricular ◽  
Low Flow ◽  
Aortic Valve Area ◽  
Stroke Work ◽  
Tei Index

Background and Aim : Low-flow, low-gradient (LFLG) severe aortic stenosis (AS) despite preserved left ventricular (LV) ejection fraction (EF) has been associated with more advanced stage of the disease, lower cardiac output (CO) and higher systemic afterload. We aim to characterize the LV performance determinants, including its vortex formation (VF) ability. Methods : Echocardiography was performed in 61 consecutive patients with severe AS (aortic valve area index (AVAI) ≤ 0.6 cm 2 /m 2 ) and preserved LVEF (≥ 50%). In addition to biplane LV measurements, AS severity indices and Tei index were measured. Hemodynamic indices (including systemic vascular resistance (SVR) and valvulo-arterial impedance (VAI)) were calculated. VF index (VFI) was obtained from 4 X (1-β)/πX α 3 X LVEF where β is the fraction of total transmitral diastolic stroke volume (SVol) contributed by atrial contraction (assessed by time velocity integral of the mitral E and A waves) and α is the end diastolic volume (EDV) 1/3 divided by mitral annular diameter during early diastole. Patients were categorized by their LV SVol index (SVI). LFLG group consisted of SVI < 45ml/m 2 . Results : Mean VFI was 2.67±1.1; AVAI, 0.50±0.09 cm 2 /m 2 . Though AVAI was slightly lower in LFLG, dimensionless index and aortic valve resistance were similar and associated with no difference in LV mass and volume between the 2 groups. VFI was significantly reduced in the LFLG, 2.37±0.9 vs 3.12±1.3 ( P =0.01), However other LV functional parameters including Tei index and LVEF were similar (Table ). LFLG was associated with higher SVR and VAI (Table ). In LFLG, the only significant correlates of VFI were SVR (r=0.38), VAI (0.37) and stroke work index (0.36); all P s<0.05. VFI did not correlate to these parameters in the non-LFLG group. Conclusion : In LFLG severe AS, increased afterload and suboptimal LV vortex formation ability contribute to lower CO/SV. VFI provides useful insights in understanding this relatively new entity. Comparison of echocardiographic and haemodynamic data in LFLG and non-LFLG groups

scholarly journals P1366 Low-flow, low-gradient severe aortic stenosis: might mitral regurgitation be a culprit?

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
J Ferreira ◽  
M Beringuilho ◽  
D Faria ◽  
D Roque ◽  
H Ferreira ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Left Ventricle ◽  
Mitral Regurgitation ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Stroke Volume ◽  
Severe Aortic Stenosis ◽  
Low Flow ◽  
Aortic Valve Area ◽  
Preserved Ejection Fraction

Abstract Introduction According to current guidelines, given a patient with low-gradient (aortic valve maximum velocity &lt; 4m/s and/or aortic valve mean gradient &lt;40mmHg), aortic valve area (AVA) &lt; 1cm2 and low-flow (stroke volume (SV) &lt; 35mL/min/m2), with preserved left ventricle function (ejection fraction (EF) ≥50%), an integrated approach for assessment of aortic stenosis severity is proposed. We aimed to investigate whether mitral regurgitation can play a role in those cases, possibly being responsible for low antegrade systolic flow. Methods We retrospectively analysed 121 consecutive transthoracic echocardiograms (TTEs) of patients with severe aortic stenosis, with AVA &lt; 1.0cm2 as assessed by continuity equation. Patients with low ejection fraction (&lt; 50%) were excluded. We therefore included 84 patients (females 53,6%, mean age 79,1+-10 years). Stroke volume was assessed by Doppler at the left ventricle outflow tract (LVOT). We then compared the prevalence of more than mild mitral regurgitation among patients with low-gradient and low-flow and the other patients. Results 15 patients had both low-gradient, low-flow and preserved ejection fraction. There was a significant association regarding the presence of more than mild mitral regurgitation among these patients (p = 0.028, OR = 4.7, CI 95% 1.1-20.1). In these patients, it was also observed a higher prevalence of atrial fibrillation (p = 0.03, OR = 6.9, CI 95% 1.74-27.1), lower longitudinal systolic function of right ventricle as measured by TAPSE (16.6 vs 21.5mm, p = 0.028), and a tendency towards higher left atrial volume (113 vs 87mL, p = 0.06). Conclusions Given the findings that the prevalence of more than mild mitral regurgitation is higher in patients with severe aortic stenosis as assessed by AVA with both low-gradient, low-flow and preserved ejection fraction, we suggest that the presence of more than mild mitral regurgitation should be considered on the approach of aortic stenosis classification of these patients.

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