Circulation Topic Review Low-Flow/Low-Gradient Aortic Stenosis
نویسنده
چکیده
Aortic stenosis (AS) is 1 of the most common valve disorders encountered in clinical practice and 1 of the most frequent indications for valve replacement surgery. Decades of research and clinical experience have resulted in the development of guidelines that provide the clinician with an evidence-based approach to the management of patients with valvular disease.1 Nonetheless, there remain patients with AS for whom management decisions are less clearly defined and who continue to pose significant diagnostic and therapeutic dilemmas. Severe AS has been defined as that associated with a valve area 1.0 cm, a mean transvalvular gradient 40 mm Hg, and a peak flow velocity 4.0 m/s. Patients with severe AS have a significant risk of cardiac morbidity and mortality2,3 and have improved symptoms and reduced mortality following aortic valve replacement (AVR).3 Traditionally, the decision to proceed with AVR in patients with AS has been based on the assessment of aortic valve area (AVA) and the presence of associated symptoms. However, as many as 30% of patients who have a calculated AVA in the severe range have other parameters suggesting mild or moderate disease (ie, mean gradient 30 mm Hg).4 These patients with lowflow/low-gradient AS (LF/LGAS) may truly have severe AS with resultant myocardial failure (true AS) or may have more moderate degrees of AS and unrelated myocardial dysfunction (pseudo-AS). In the latter setting, the aortic valve may appear severely stenotic as a result of the flow-dependent nature of the valve area calculation by either invasive or noninvasive techniques,5 and the inability of the myopathic ventricle to generate adequate force to fully open the valve. Distinguishing between these possibilities has important clinical implications in regard to prognosis and management options, as patients with true AS will likely benefit from corrective valve surgery, whereas patients with pseudo-AS may not.
منابع مشابه
Assessment of low-gradient aortic stenosis with dobutamine.
Low-gradient aortic stenosis (AS) has been a vexing problem for cardiologists since its original description in 1980 by Carabello et al.1 In that study, 3 of 4 patients with low-gradient AS died at surgery, and the other patient had persistent severe heart failure postoperatively. Subsequent studies showed that although operative mortality is high, most patients survive aortic valve replacement...
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catheterization study. Circulation 2013;128:S235–S242. 18. Dumesnil JG, Pibarot P. Letter by Dumesnil and Pibarot regarding article, ‘Outcome of patients with low-gradient ‘severe’ aortic stenosis and preserved ejection fraction’. Circulation 2011;124:e360. 19. Cueff C, Serfaty JM, Cimadevilla C, Laissy JP, Himbert D, Tubach F, Duval X, Iung B, Enriquez-Sarano M, Vahanian A, Messika-Zeitoun D. ...
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Aortic stenosis (AS) remains a common and important clinical entity and, when severe, is associated with significant morbidity and mortality. Fortunately, definitive surgical therapies have been developed that have significantly altered the natural history of this disease. The clinical challenge is to accurately assess AS severity and identify patients who are most likely to benefit from aortic...
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BACKGROUND Patients with low-flow, low-gradient aortic stenosis have a poor prognosis with conservative therapy but a high operative mortality if treated surgically. Recently, we proposed a new index of aortic stenosis severity derived from dobutamine stress echocardiography, the projected aortic valve area at a normal transvalvular flow rate, as superior to other conventional indices to differ...
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