Severe isolated aortic stenosis with normal left ventricular systolic function and low transvalvular gradients: Pathophysiologic and prognostic insights

Eddy Barasch, Dali Fan, Ebere O. Chukwu, Jing Han, Michael Passick, Florentina Petillo, Aracely Norales, Nathaniel Reichek

Research output: Contribution to journalArticlepeer-review

89 Scopus citations

Abstract

Background and aim of the study: A significant proportion of patients with severe valvular aortic stenosis (AS) and preserved left ventricular (LV) systolic function have low transvalvular gradients. The study aim was to determine the mechanisms and outcome of patients with this hemodynamic profile of AS. Methods: Among 1,679 patients who underwent transthoracic echocardiography for the evaluation of AS at the authors' institution, 215 (105 females, 110 males; mean age: 77 ± 10 years) had isolated AS (mean aortic valve area index 0.39 ± 0.1 cm2/m2), normal sinus rhythm and normal LV ejection fraction. The mean follow up was 23 ± 12 months, and the end-points were mortality, aortic valve replacement (AVR), or mortality or AVR. Results: Forty-seven patients had a transvalvular mean gradient (MG) <30 mmHg (MGlow and 168 had MG ≥30 mmHg (MG high). Compared to MGhigh, the MGlow group had a higher prevalence of hypertension, lower LV end-diastolic volume index (47 ± 9 versus 56 ± 12 ml/m2, p <0.0001), lower LV stroke volume index (37 ± 12 versus 41 ± 11 ml/beat, p <0.0002), a lesser severity of stenosis (aortic valve area index 0.37 ± 0.09 versus 0.46 ± 0.09 cmVm2, p <0.0001) and a higher systemic vascular resistance (2163 ± 754 versus 1879 ± 528 dyne·cnv·s-5. The LV end-diastolic volume index, systemic vascular resistance and energy loss index were predictors of MG <30 mmHg (OR = 0.30, 95% CI, 0.12, 0.62; OR = 3.05, 95% CI, 1.71, 6.26; and OR = 6.76, 95% CI, 3.44,15.38, respectively). MG <30 mmHg (MGhigh) was associated with almost 50% lower referral to surgery and a two-fold increase in preoperative mortality. Conclusion: In severe AS with a normal LV ejection fraction, MG <30 mmHg is related to a lesser severity of stenosis, a smaller LV volume, a lower flow rate and a higher systemic vascular resistance. Compared to the MGhigh group, these patients were less frequently referred to surgery and had a higher mortality.

Original languageEnglish (US)
Pages (from-to)81-88
Number of pages8
JournalJournal of Heart Valve Disease
Volume17
Issue number1
StatePublished - Jan 2008
Externally publishedYes

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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