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 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

Clinical and echocardiographic outcomes of patients with moderate to severe aortic stenosis and preserved, mid-range and reduced ejection fraction

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
N Chew ◽  
N Ngiam ◽  
B.Y.Q Tan ◽  
C.H Sia ◽  
H.W Sim ◽  
...  
Keyword(s):  
Heart Failure ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Aortic Valve Area ◽  
Ventricular Ejection Fraction ◽  
All Cause Mortality

Abstract Background Left ventricular ejection fraction (EF) plays an important role in risk stratifying and guiding therapy for patients with aortic stenosis (AS). This study aims to describe the clinical and echocardiographic outcomes of AS patients with preserved (ASpEF), mid-range (ASmrEF) and reduced (ASrEF) EF. Methods 713 consecutive patients with index echocardiographic diagnosis of moderate-severe AS (aortic valve area &lt;1.5cm2) were allocated according to the EF into three groups: ASrEF (EF&lt;40%), ASmrEF (EF 40–50%), and ASpEF (EF&gt;50%). The study outcomes were defined as 5-year all-cause mortality, heart failure admissions, and aortic valve replacement (AVR). Results In comparison to patients with ASpEF, those with ASrEF were more frequently male, and systolic blood pressure was significantly lower on enrolment (p&lt;0.001). Diabetes, ischemic heart disease and atrial fibrillation were more commonly seen in the ASrEF and ASmrEF groups, compared to ASpEF group. All-cause mortality rates were 30.5% for ASpEF, 50.8% for ASmrEF, 55.0% for ASrEF groups (p&lt;0.001). Increased rates of heart failure admissions were seen in the ASmrEF and ASrEF groups (30.5% and 33.9%, respectively, vs. 14.9% in ASpEF group). Patients with ASrEF had significantly higher rates of AVR as compared to those in the ASmrEF and ASpEF groups (p=0.032). Conclusion Echocardiographic and clinical outcomes of ASmrEF patients resembled those of ASrEF more closely than the ASpEF patients. Stratifying AS patients according to the different EF groups may improve risk assessment and treatment strategies. Figure 1 Funding Acknowledgement Type of funding source: None

Abstract 15001: Fusion of Echocardiographic Hemodynamic Data and Computed Tomographic Anatomical Data of the Aortic Valve Determine Severity of Low-Gradient Aortic Stenosis with Preserved Ejection Fraction

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Vasileios Kamperidis ◽  
Philippe J van Rosendael ◽  
Spyridon Katsanos ◽  
Frank van der Kley ◽  
Madelien Regeer ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Low Flow ◽  
Normal Flow ◽  
Area Index ◽  
High Gradient ◽  
Calcium Load

Introduction: Severe aortic stenosis with preserved left ventricular ejection fraction is classified into 4 groups, according to flow and gradient, with still debatable underlying pathophysiology. Hypothesis: The use of multi-detector computed tomography (MDCT) and Doppler echocardiography refines the differential characteristics and true severity of each aortic stenosis group. Methods: Patients with severe aortic stenosis [aortic valve area index (AVAi) <0.6cm2/m2] and ejection fraction ≥50% (n=191, age 80±7 years, 48.2% male) with echocardiography and MDCT prior to transcatheter aortic valve replacement were included. Patients were classified into 4 groups based on stroke volume index (≤35 or >35 ml/m2) and mean pressure gradient (≤40 or >40mmHg): 1. Normal-flow, high-gradient, 2. Low-flow, high-gradient, 3. Normal-flow, low-gradient, 4. Low-flow, low-gradient. Aortic valve calcium was evaluated on MDCT. Fusion AVAi was estimated by continuity equation using Doppler hemodynamics and MDCT left ventricular outflow tract (LVOT) area. Results: AVAi and LVOT area index were both significantly different among the 4 groups when evaluated by echocardiography. On MDCT, although LVOT area index was comparable among groups, fusion AVAi remained significantly different (Figure): normal-flow, low-gradient had the largest area (0.62±0.11cm2/m2), resulting in reclassification into moderate stenosis in 52% of these patients, while low-flow, low-gradient group had comparable fusion AVAi to normal-flow, high-gradient group. Aortic valve calcium load was largest among patients with high-gradient (median 3412AU for normal-flow and 3181AU for low-flow) and was comparable between patients with low-gradient (2143AU for normal-flow and 2310AU for low-flow). Conclusion: MDCT refines the hemodynamic characterization of low gradient AS patients by providing more accurate AVAi estimation and calcium load.

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.

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

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 &lt;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 &gt;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 &lt;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&lt;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&lt;0.01. As expected, flow was decreased in LFLG (163±20 ml/s, p&lt;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

scholarly journals Valvulo-Arterial Impedance and Dimensionless Index for Risk Stratifying Patients With Severe Aortic Stenosis

2021 ◽  
Vol 8 ◽  
Author(s):  
Yogamaya Mantha ◽  
Shutaro Futami ◽  
Shohei Moriyama ◽  
Michinari Hieda
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Continuous Wave ◽  
Left Ventricular ◽  
Low Flow ◽  
Aortic Valve Area ◽  
Arterial Impedance ◽  
Stenosis Severity ◽  
Lv Ejection Fraction

The hemodynamic effects of aortic stenosis (AS) consist of increased left ventricular (LV) afterload, reduced myocardial compliance, and increased myocardial workload. The LV in AS patients faces a double load: valvular and arterial loads. As such, the presence of symptoms and occurrence of adverse events in AS should better correlate with calculating the global burden faced by the LV in addition to the transvalvular gradient and aortic valve area (AVA). The valvulo-arterial impedance (Zva) is a useful parameter providing an estimate of the global LV hemodynamic load that results from the summation of the valvular and vascular loads. In addition to calculating the global LV afterload, it is paramount to estimate the stenosis severity accurately. In clinical practice, the management of low-flow low-gradient (LF-LG) severe AS with preserved LV ejection fraction requires careful confirmation of stenosis severity. In addition to the Zva, the dimensionless index (DI) is a very useful parameter to express the size of the effective valvular area as a proportion of the cross-section area of the left ventricular outlet tract velocity-time integral (LVOT-VTI) to that of the aortic valve jet (dimensionless velocity ratio). The DI is calculated by a ratio of the sub-valvular velocity obtained by pulsed-wave Doppler (LVOT-VTI) divided by the maximum velocity obtained by continuous-wave Doppler across the aortic valve (AV-VTI). In contrast to AVA measurement, the DI does not require the calculation of LVOT cross-sectional area, a major cause of erroneous assessment and underestimation of AVA. Hence, among patients with LG severe AS and preserved LV ejection fraction, calculation of DI in routine echocardiographic practice may be useful to identify a subgroup of patients at higher risk of mortality who may derive benefit from aortic valve replacement. This article aims to elucidate the Zva and DI in different clinical situations, correlate with the standard indexes of AS severity, LV geometry, and function, and thus prove to improve risk stratification and clinical decision making in patients with severe AS.

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

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.

scholarly journals Natural Progression of Low-Gradient Severe Aortic Stenosis with Preserved Ejection Fraction

2014 ◽  
Vol 41 (3) ◽  
pp. 273-279 ◽  
Author(s):  
Antony Leslie Innasimuthu ◽  
Sanjay Kumar ◽  
Jason Lazar ◽  
William E. Katz
Keyword(s):  
Aortic Stenosis ◽  
Ejection Fraction ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Aortic Valve Area ◽  
Ventricular Ejection Fraction ◽  
Mild Stenosis ◽  
Natural Progression

Because the natural progression of low-gradient aortic stenosis (LGAS) has not been well defined, we performed a retrospective study of 116 consecutive patients with aortic stenosis who had undergone follow-up echocardiography at a median interval of 698 days (range, 371–1,020 d). All patients had preserved left ventricular ejection fraction (&gt;0.50) during and after follow-up. At baseline, patients were classified by aortic valve area (AVA) as having mild stenosis (≥1.5 cm2), moderate stenosis (≥1 to &lt;1.5 cm2), or severe stenosis (&lt;1 cm2). Severe aortic stenosis was further classified by mean gradient (LGAS, mean &lt;40 mmHg; high-gradient aortic stenosis [HGAS], mean ≥40 mmHg). We compared baseline and follow-up values among 4 groups: patients with mild stenosis, moderate stenosis, LGAS, and HGAS. At baseline, 30 patients had mild stenosis, 54 had moderate stenosis, 24 had LGAS, and 8 had HGAS. Compared with the moderate group, the LGAS group had lower AVA but similar mean gradient. Yet the actuarial curves for progressing to HGAS were significantly different: 25% of patients in LGAS reached HGAS status significantly earlier than did 25% of patients in the moderate-AS group (713 vs 881 d; P=0.035). Because LGAS has a high propensity to progress to HGAS, we propose that low-gradient aortic stenosis patients be closely monitored as a distinct subgroup that warrants more frequent echocardiographic follow-up.

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