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.
Post-extrasystolic potentiation differentiates “true” from “pseudo” Low-flow, Low-gradient aortic stenosis
