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2016 ; 37
(34
): 2645-57
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Low-gradient aortic stenosis
#MMPMID27190103
Clavel MA
; Magne J
; Pibarot P
Eur Heart J
2016[Sep]; 37
(34
): 2645-57
PMID27190103
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An important proportion of patients with aortic stenosis (AS) have a
'low-gradient' AS, i.e. a small aortic valve area (AVA <1.0 cm(2)) consistent
with severe AS but a low mean transvalvular gradient (<40 mmHg) consistent with
non-severe AS. The management of this subset of patients is particularly
challenging because the AVA-gradient discrepancy raises uncertainty about the
actual stenosis severity and thus about the indication for aortic valve
replacement (AVR) if the patient has symptoms and/or left ventricular (LV)
systolic dysfunction. The most frequent cause of low-gradient (LG) AS is the
presence of a low LV outflow state, which may occur with reduced left ventricular
ejection fraction (LVEF), i.e. classical low-flow, low-gradient (LF-LG), or
preserved LVEF, i.e. paradoxical LF-LG. Furthermore, a substantial proportion of
patients with AS may have a normal-flow, low-gradient (NF-LG) AS: i.e. a small
AVA-low-gradient combination but with a normal flow. One of the most important
clinical challenges in these three categories of patients with LG AS (classical
LF-LG, paradoxical LF-LG, and NF-LG) is to differentiate a true-severe AS that
generally benefits from AVR vs. a pseudo-severe AS that should be managed
conservatively. A low-dose dobutamine stress echocardiography may be used for
this purpose in patients with classical LF-LG AS, whereas aortic valve calcium
scoring by multi-detector computed tomography is the preferred modality in those
with paradoxical LF-LG or NF-LG AS. Although patients with LF-LG severe AS have
worse outcomes than those with high-gradient AS following AVR, they nonetheless
display an important survival benefit with this intervention. Some studies
suggest that transcatheter AVR may be superior to surgical AVR in patients with
LF-LG AS.
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