Development of paradoxical low-flow, low-gradient severe aortic stenosis. Issue 13 (20th March 2015)

• Record Type: Journal Article
• Authors: Dahl, Jordi S; Eleid, Mackram F; Pislaru, Sorin V; Scott, Christopher G; Connolly, Heidi M; Pellikka, Patricia A
• Is Part Of: Heart. Volume 101:Issue 13(2015)
• Page Start: 1015
• Page End: 1023
• Publication Date: 2015-03-20
• Subjects: Heart -- Diseases -- Treatment -- Periodicals; Cardiology -- Periodicals; 616.12
• DOI: 10.1136/heartjnl-2014-306838
• Languages: English
• ISSNs: 1355-6037

Abstract

Abstract : Objective: Among patients with severe aortic stenosis (sAS) and preserved LVEF, those with low-flow, low-gradient sAS (LFLG-sAS) have an adverse prognosis. It has been proposed that LFLG-sAS represents an end-stage point of sAS, but longitudinal information has not been described. The aim was to determine whether LFLG-sAS represents an end-stage consequence of normal-flow, high-gradient sAS (NFHG-sAS) or a different entity. Methods: From our transthoracic echocardiogram (TTE) database, we identified patients with sAS (aortic valve area <1 cm 2 ) and preserved LVEF (≥50%), and from these, patients with LFLG-sAS (stroke volume index <35 mL/m 2 and mean transvalvular gradient <40 mm Hg) who had ≥1 additional TTE within five years prior to the index TTE. Patients were age/sex/date matched 2:1 with patients with NFHG-sAS and normal-flow, low-gradient (NFLG)-sAS who also had ≥1 TTE. Included were 1203 TTEs (383 index studies and 820 preceding studies). Results: In 78 patients with LFLG-sAS, an HG stage preceded the index TTE in only 4 (5%). During the five years preceding the index TTE, patients with LFLG-sAS developed increasing relative wall thickness (0.42 to 0.49; p<0.001) without change in LV mass index. Patients with NFHG-sAS had a marked increase in LV mass index (87 to 115 g/m 2 ; p<0.001). Patients with LFLG-sAS demonstrated the greatest reduction in LV end-diastolic diameters (−3 vs −1 for NFLG-sAS vs +2 mm for NFHG-sAS; p=0.001), deceleration time (−55 vs −3 vs +3 ms, respectively; p<0.01) and LVEF (−4 vs 0 vs 0%, respectively; p=0.01). Conclusions: LFLG-sAS is a distinct presentation of sAS preceded by a unique remodelling pathway and is uncommonly preceded by an HG stage.