229 Long-term clinical and echocardiographic outcome following TAVR in patients with severe aortic stenosis and different transvalvular flow state

Abstract Aims Haemodynamic classifications of severe aortic stenosis (AS) have important prognostic implications, with low flow state (defined on the basis of a stroke volume index, SVi<35 mL/m2) known to be a predictor of worse prognosis. As transcatheter aortic valve replacement (TAVR) has become widely used for patients with severe AS, issues were raised concerning its efficacy in patients with different haemodynamic classifications combining transvalvular flow state and pressure gradients. In fact, data on TAVR outcomes in patients with low gradient (LG) AS are limited and in some cases controversial. The aim of this study was to evaluate the efficacy and long-term clinical and echocardiographic outcome of TAVR in patients with different transvalvular flow-gradient patterns. Methods In this single centre study, 1078 patients (mean age 81±7 years) with severe symptomatic AS (AVA<1 cm2) undergoing TAVR were categorized according to flow-gradient patterns as follow: 867 patients (80%) with normal flow-high gradient (NF-HG: mean transaortic gradient DP mean>40 mmHg), 94 (9%) with paradoxical low flow LG (pLF-LG: DP mean<40 mmHg, ejection fraction EF > 50%, and SVi<35 mL/m2), and 117 (11%) classical LF-LG (DP mean<40 mmHg, EF < 50%, SVi<35 mL/m2). Results TAVR was feasible in all AS subtypes with similar rate of unsuccessful procedure (1.3% NF-HG, 1.1% pLF-LG, 0% LF-LG P=470). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group (Figure A). Overall, intraoperative (P=957) and 30-day mortality (P=817) did not differ significantly among the 3 groups. Longer follow-up showed that, compared to NF-HG patients, pLF-LG had similar all-cause mortality rate [HR 1.35(0.95–1.90), P=0.094] up to 5 years and LF-LG had a significant higher mortality rate [HR 1.89(1.43–2.49), P<0.001],(Figure B). Moreover, LF-LG patients had higher rehospitalization for heart failure (NF-HG: 3%, pLF-LG: 6%, LF-LG 10%, P=0.001). Conclusions We provided evidence that TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. A careful haemodynamic classifications of severe AS is of utmost importance for identifying patients who benefits the most from TAVR procedure.

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Demographic characteristics, aortic valve intervention rates and all-cause mortality in 4 flow-gradient sub-types of severe aortic stenosis

European Heart Journal ◽

10.1093/ehjci/ehaa946.0060 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S Saeed ◽

A Vamvakidou ◽

H.Y Yakupoglu ◽

R Senior ◽

R.S Khattar

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Stroke Volume Index ◽

Low Flow ◽

Volume Index ◽

Mortality Data ◽

Aortic Valve Area ◽

Flow Gradient ◽

All Cause Mortality

Abstract Introduction Severe aortic stenosis (AS), defined as aortic valve area (AVA) <1.0 cm2, can be divided into 4 categories based on flow status and mean gradient. Stroke volume index <35 ml/m2 has classically been used to define low flow, but recent data suggest that flow rate (FR) <200ml/sec may be a more accurate and robust marker of low flow. Methods We prospectively collected demographic, echocardiographic, aortic valve intervention (AVI) and all-cause mortality data on 1562 patients with symptomatic severe AS from 2010 to 2017 with a mean follow up period of 35±22 months. Patients were divided into 4 flow-gradient sub-groups based on a FR threshold of 200ml/s and mean pressure gradient of 40mmHg. Comparative analyses were performed among the 4 groups using analysis of variance. Results The prevalence of normal flow high gradient (NFHG) severe AS was 30%, NF low gradient (NFLG) 21%, low flow HG (LFHG) 18% and LFLG 31% (Table). Across these 4 sub-groups, there was a graded reduction in LVEF and FR, and an increase in age and all–cause mortality. Conclusions Classification of aortic stenosis based on flow-gradient patterns, shows important differences in the demographic profile and clinical outcome among the 4 groups. Classical NFHG AS was associated with the highest rate of AVI and lowest all-cause mortality compared to the 3 discordant flow-gradient subtypes. The LFLG group had the lowest AVI rates and worst outcome. Funding Acknowledgement Type of funding source: None

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Impact of the Trifecta bioprosthetic valve in patients with low-flow severe aortic stenosis

Heart and Vessels ◽

10.1007/s00380-021-01802-5 ◽

2021 ◽

Author(s):

Tohru Takaseya ◽

Atsunobu Oryoji ◽

Kazuyoshi Takagi ◽

Tomofumi Fukuda ◽

Koichi Arinaga ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Stroke Volume Index ◽

Low Flow ◽

Volume Index ◽

Effective Orifice Area ◽

Aortic Valve Area ◽

Hemodynamic Performance ◽

Mid Term Results

AbstractAortic stenosis (AS) is the most common valve disorder in advanced age. Previous reports have shown that low-flow status of the left ventricle is an independent predictor of cardiovascular mortality after surgery. The Trifecta bioprosthesis has recently shown favorable hemodynamic performance. This study aimed to evaluate the effect of the Trifecta bioprosthesis, which has a large effective orifice area, in patients with low-flow severe AS who have a poor prognosis. We retrospectively evaluated 94 consecutive patients with severe AS who underwent aortic valve replacement (AVR). Patients were divided into two groups according to the stroke volume index (SVI): low-flow (LF) group (SVI < 35 ml/m2, n = 22) and normal-flow (NF) group (SVI ≥ 35 ml/m2, n = 72). Patients’ characteristics and early and mid-term results were compared between the two groups. There were no differences in patients’ characteristics, except for systolic blood pressure (LF:NF = 120:138 mmHg, p < 0.01) and the rate of atrial fibrillation between the groups. A preoperative echocardiogram showed that the pressure gradient was higher in the NF group than in the LF group, but aortic valve area was similar. The Trifecta bioprosthesis size was similar in both groups. The operative outcomes were not different between the groups. Severe patient–prosthesis mismatch (PPM) (< 0.65 cm2/m2) was not observed in either of the groups. There were no significant differences in mid-term results between the two groups. The favorable hemodynamic performance of the Trifecta bioprosthesis appears to have the similar outcomes in the LF and NF groups. AVR with the Trifecta bioprosthesis should be considered for avoidance of PPM, particularly in AS patients with LV dysfunction.

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Left ventricular mechanical dispersion in flow-gradient patterns of severe aortic stenosis

European Heart Journal ◽

10.1093/ehjci/ehaa946.0099 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

D Lavall ◽

L.K Kuprat ◽

J Kandels ◽

S Stoebe ◽

A Hagendorff ◽

...

Keyword(s):

Aortic Stenosis ◽

Longitudinal Strain ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Low Flow ◽

Volume Index ◽

Aortic Valve Area ◽

Mechanical Dispersion ◽

Flow Gradient ◽

Valve Area

Abstract Purpose Patients with severe aortic stenosis are classified according to flow-gradient patterns. We investigated whether left ventricular (LV) mechanical dispersion, a marker of dyssynchrony and predictor of mortality, is associated with low-flow status in aortic stenosis. Methods and results 400 consecutive patients with QRS duration <120ms were included in the retrospective analysis. Patients with severe aortic stenosis (aortic valve area ≤1.0cm2) were classified as normal-flow (NF; stroke volume index >35ml/m2) high-gradient (HG; mean transvalvular gradient ≥40mmHg) (n=79), NF low-gradient (LG) (n=62), low-flow (LF) LG ejection fraction (EF) ≥50% (n=57), and LF LG EF<50% (n=23). Patients with moderate aortic stenosis (aortic valve area 1.5–1.0cm2; n=95) and patients with chronic systolic heart failure (n=84) without aortic stenosis served as comparison groups. Similar values of mechanical dispersion (calculated as standard deviation of time from Q/S onset on electrocardiogram to peak longitudinal strain in 17 left ventricular segments) was observed in patients with NF HG (49.4±14.7ms), NF LG (43.5±12.9ms), LF LG EF≥50% (47.2±16.3ms) and moderate aortic stenosis (44.2±15.7ms). Mechanical dispersion was increased in patients with LF LG EF<50% (60.8±20.7ms) and in chronic heart failure (59.4±16.7ms) (p<0.05 for both vs. NF HG‡, NF LG†, LF LG EF≥50%§ and moderate*; Figure). Mechanical dispersion correlated with LV end-systolic volume index (r=0.2530, p<0.0001), LVEF (r=−0.2895, p<0.0001) and global longitudinal strain (r=0.3108, p<0.0001), but not with parameters of aortic stenosis. Conclusion Mechanical dispersion was similar among flow-gradient subgroups of severe aortic stenosis with preserved LVEF, but increased in patients with low-flow low-gradient and reduced LVEF. These findings indicate that mechanical dispersion is rather a marker of systolic myocardial dysfunction than of aortic stenosis. Figure 1 Funding Acknowledgement Type of funding source: None

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P6470Ventriculo-arterial coupling in severe aortic stenosis: does the flow-gradient pattern play a role?

European Heart Journal ◽

10.1093/eurheartj/ehz746.1062 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

A E Vijiiac ◽

C Neagu ◽

A Cherry ◽

S Onciul ◽

D Zamfir ◽

...

Keyword(s):

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Stroke Volume Index ◽

Left Ventricular ◽

Low Flow ◽

Volume Index ◽

Aortic Valve Area ◽

Arterial Elastance ◽

Ventricular Elastance ◽

Flow Gradient

Abstract Background Ventriculo-arterial coupling (VAC) assesses the interplay between ventricular contractility and afterload and it is calculated as the ratio between arterial elastance (Ea) and end-systolic left ventricular elastance (EES). Severe aortic stenosis (AS) carries different configurations according to transvalvular flow rates and pressure gradients and each of these entities has its particularities in terms of physiology and clinical outcome. Little has been studied so far regarding the changes of VAC in severe AS. Purpose We sought to assess the VAC non-invasively in patients (pts) with severe AS and to characterize it according to the flow-gradient pattern. Methods We included 61 consecutive pts with severe AS (78±13 years, 30 men, indexed aortic valve area <0.6 cm2/m2), for whom we performed a comprehensive echocardiography. VAC was determined as the ratio between Ea and EES. Patients were divided in 4 groups, depending on stroke volume index (low-flow [LF] vs. normal-flow [NF]: 35 ml/m2) and mean transaortic pressure gradient (low-gradient [LG] vs. normal gradient [NG]: 40 mm Hg). This resulted in the following flow-gradient patterns: LFLG, LFNG, NFLG, NFNG. Data were compared between groups with one-way analysis of variance and then with a Tukey test. Results There were 11 pts (18%) in the LFLG group, 20 pts (32.8%) in the LFNG group, 8 pts (13.2%) in the NFLG group and 22 pts (36%) in the NGNG group. The arterial elastance was highest in the LFLG group: 3.37±1.49 vs. 2.79±0.92 in the LFNG, 2.05±0.57 in the NFLG and 1.54±0.49 in the NFNG group (p<0.001). The ventricular elastance was also highest in the LFLG group (4.03±2.46) vs. 3.16±1.33 in the LFNG, 2.21±1.22 in the NFLG and 2.29±0.78 in the NFNG group (p=0.007). VAC was most impaired in the NFLG group (1.35±1.08), followed by LFNG group (1.00±0.47), LFLG group (0.93±0.27) and NFNG group (0.70±0.14) (p=0.01). Valvulo-arterial impedance (ZVA) was highest in the LFNG group: 7.78±2.15, followed by 7.38±2.17 in the LFLG group, 4.93±1.17 in the NFLG group and 4.33±1.23 in the NFNG group (p<0.001). VAC and ZVA showed no significant correlation (p=0.27), with VAC being significantly more impaired in patients with abnormal ZVA (>4.5 mm Hg/ml/m2): 0.99±0.60 vs. 0.73±0.20 (p=0.02). Conclusion The ventriculo-vascular interaction in severe AS varies noticeably according to the flow-gradient pattern. Low-gradient states, particularly NFLG, have the most impaired VAC. This study supports the idea that these 4 configurations are different clinical entities and it highlights the importance of integrating the flow-gradient pattern for a comprehensive evaluation of AS severity. Acknowledgement/Funding This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF

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Severe aortic stenosis echocardiographic thresholds revisited

European Heart Journal ◽

10.1093/eurheartj/ehab724.0112 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

S Schwartzenberg ◽

M Vaturi ◽

M Wiessman ◽

A Shechter ◽

O Morelli ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Prognostic Value ◽

Severe Aortic Stenosis ◽

Low Flow ◽

Volume Index ◽

Doppler Velocity ◽

Aortic Valve Area ◽

Discriminative Value ◽

Group B

Abstract Background In view of inconsistencies in threshold values of severe aortic stenosis (AS) hemodynamic indices, it is unclear what is the relative contribution of each variable in a binary classification of AS based on aortic valve replacement (AVR) indication. Purpose Assess relative discriminative value and optimal threshold of each constituent hemodynamic parameter for this classification and confirm additional prognostic value. Methods Echocardiography studies of 168 patients with ≥ moderate AS were included. AS types were dichotomized based on intervention implication into two groups: Group-A, comprising moderate and Normal-Flow Low-Gradient (NFLG), and Group-B, comprising High-Gradient (HG), Low Ejection Fraction Low-Flow Low-Gradient (Low EF-LFLG), and Paradoxical Low-Flow Low-Gradient (PLFLG) AS. Aortic valve area (AVA), Doppler velocity index (DVI), peak aortic velocity, mean gradient and stroke volume index were assessed for A/B Group discrimination value and optimal thresholds were determined. Dichotomized values were assessed for predictive value for AVR or death. Results C-statistic values for binary AS classification was 0.74–0.9 for the tested variables. AVA and DVI featured the highest score, and SVI the lowest one. AVA≤0.81 cm2 and DVI≤0.249 had 87.6% and 86% respective sensitivity for Group B patients, and a similar specificity of 80.9%. During a mean follow-up of 9.1±10.1 months, each of the tested dichotomized variables except for SVI predicted AVR or death on multivariate analysis. Conclusion An AVA value ≤0.81 cm2 or a DVI ≤0.249 threshold carry the highest discriminative value for severe AS in patients with aortic stenosis, translating into an independent prognostic value, and should be considered in clinical decisions. FUNDunding Acknowledgement Type of funding sources: None. Echo variables correlation with Group B Survival curves for individual AS types

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Ejection dynamics and valve kinetics in patients with low-gradient severe aortic stenosis with preserved ejection fraction. Comparison between normal and low-flow

European Heart Journal ◽

10.1093/ehjci/ehaa946.1865 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

R Migliore ◽

M.E Adaniya ◽

M.A Barranco ◽

S Gonzalez ◽

G Miramont

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Ejection Fraction ◽

Stroke Volume ◽

Severe Aortic Stenosis ◽

Aortic Flow ◽

Low Flow ◽

Volume Index ◽

Aortic Valve Area ◽

Preserved Ejection Fraction

Abstract Background Studies of ejection dynamics in severe aortic stenosis and prosthetic valve obstruction had demonstrated a delay in aortic valve opening. Purpose The aim of this study was to compare and evaluate ejection dynamics and valve kinetics in patients with severe aortic stenosis with preserved ejection fraction with normal and low flow. Methods 83 patients (age average 68±11 years) with severe aortic stenosis (aortic valve area <1cm2) and preserved ejection fraction (≥50%) were studied with Doppler echocardiography and included prospectively. The ratio of aortic valve area measured at mid-deceleration and mid-acceleration (Md/Ma) were calculated using velocity of left ventricular outflow tract and aortic transvalvular velocity in continuity equation as an index of valvular kinetics. A ratio of Md/Ma >1 indicate delay in opening of aortic valve. Assessment of ejection dynamics was evaluated with acceleration time (AT), ejection time (ET) and the ratio AT/ET estimated from aortic Doppler velocities profiles. Aortic flow was calculated as stroke volume/ET. According to stroke volume index and mean gradient patients were classified in 3 groups: normal-flow, low-gradient (NFLG) 25 patients, low-flow, low-gradient (LFLG) 28 patients and normal-flow, high-gradient (HG) 30 patients. Analysis of the variance and coefficient of correlation “r” were used for statistical evaluation. A p value <0.05 was considered significant. Results There was no significant difference among the 3 groups with regard to ratio Md/Ma: NFLG 1.29±0.38, LFLG 1.22±0.26 and HG 1.23±0.45, NS. No difference was found in AT in the 3 groups, but ET was shorter in LFLG (310±30 ms) in comparison with NFLG (345±32 ms) and HG (361±31 ms), p<0.01. Ratio AT/ET occurred in early systole in NFLG (0.27±0.07) compared with LFLG (0.32±0.07) and HG (0.39±0.07), p<0.01. As expected, flow was decreased in LFLG (163±20 ml/s, p<0.001) compared with NFLG (217±13 ml/s) and HG (233±44 ml/s). There was no correlation among AT/ET and aortic flow or stroke volume index. Conclusions There were not differences among the groups with regard to kinetic of the valve evaluated by mean of ratio Md/Ma. According to ratio AT/ET, aortic valve takes less time to open in NFLG compared with LFLG and HG independent of aortic flow suggesting a different ejection dynamics pattern in this group. Funding Acknowledgement Type of funding source: None

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

Circulation Cardiovascular Imaging ◽

10.1161/circimaging.120.012453 ◽

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.

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

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.143 ◽

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 < 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 < 40mmHg + AVA ≤ 1.0cm², n = 155) and moderate AS (Mod-AS, mPG < 40mmHg + AVA > 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 < 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 < 0.001, figure B). This trend persisted even when analysed separately for norml (stroke volume index > 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 < 0.001, figure D). Conclusion This study confirmed the clinical efficacy of RES for risk-stratifying LG-AS patients. Abstract P289 Figure.

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

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.805 ◽

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 <≥50%), aortic valve area (AVA<≥1cm2), mean pressure gradient (MG<≥40mmHg), peak velocity<≥400 cm/sec, and stroke-volume index (SVI<≥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.

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

European Heart Journal ◽

10.1093/eurheartj/ehab724.0120 ◽

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 <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

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