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Assessment and management of to have low-gradient, low ejection frac-

tion AS without CR, but the severity of
AS remains undetermined. In these
low-gradient, low ejection patients, severe aortic valve calcification
on echocardiography, fluoroscopy or CT

fraction aortic stenosis is an indicator of considerable AS.


Christophe Tribouilloy, Franck Lévy SURGERY?
In selected patients with low-gradient,
low ejection fraction AS, aortic valve
Low-gradient, low ejection fraction aortic et al,6 dobutamine echocardiography is
replacement (AVR) is associated with a
stenosis (AS) represents about 5–10% of extremely helpful to potentially distin-
dramatic improvement of long-term sur-
all cases of severe AS and is the most guish severe from non-severe AS.
vival compared with medical manage-
challenging subgroup of patients to man- Dobutamine may increase the stroke
ment.2 7 11 12 Moreover, among patients
age.1 2 The term low-gradient, low ejec- volume (SV) and consequently the aortic
who survive AVR, an improvement in
tion fraction AS is usually applied to transvalvular flow. Contractile reserve
functional status is usually seen and the
patients with a mean gradient ,30 mm (CR) during dobutamine echocardiogra-
EF increases by at least 10% in more than
Hg (or 40 mm Hg), an aortic valve area phy is currently defined by an increase of
80% of cases.4 Perioperative mortality in
(AVA) ,1 cm2, and an ejection fraction SV .20%.2 7 In pseudo-severe AS, an
low-gradient, low ejection fraction AS
(EF) ,35% (or 40%).1–7 Low EF in such increase of SV results in an increase of ranges from 8 to 21% in recent publica-
patients may be caused by severe low- AVA to reach a non-severe range tions.1 3 7 11 12
flow AS with inadequate compensatory (.1.2 cm2), whereas the gradient In a multicentre European study, we
left ventricular hypertrophy, called after- (,30 mm Hg) is not significantly altered reported a significant decrease of opera-
load mismatch, but also by another owing to the larger AVA.3 The additional tive mortality, from 20% in the 1990s to
myocardial disease (such as extensive value of a new index derived from 10% over the past 5 years.12 Perioperative
fibrosis, associated cardiomyopathy or dobutamine echocardiography, the pro- mortality and lower long-term postopera-
myocardial infarction (MI)),5 in which jected effective AVA at a flow rate of tive survival are mainly related to older
case, AS is not the primary problem. The 250 ml/s, has been proposed to distin- age, presence of comorbidities, very low
essential difficulty for clinicians is to guish patients with true severe low- pressure gradient (,20 mm Hg), severe
distinguish true severe low-flow AS, gradient, low ejection fraction AS from associated coronary artery disease or
responsible for low EF, from pseudo- patients with pseudo-severe disease.8 history of MI, and absence of CR with
severe AS comprising mild-to-moderate In this issue of Heart, Burwash et al, dobutamine.1 12 A high operative mortal-
AS associated with another cause of left using dynamic positron emission tomo- ity of about 30% is reported in patients
ventricular dysfunction (LVD). A very graphy, demonstrate that patients with with low-gradient AS without CR.2 4 7 12
low gradient may be seen in true severe true severe low-gradient, low ejection Conversely, those patients with CR had
low-flow AS, while the decreased AVA fraction AS have a marked tendency to an operative mortality of only 5–8%.
seen in pseudo-severe AS reflects poor higher resting myocardial blood flow and Patients with severe AS and CR therefore
opening of the aortic valve directly related more severe impairment of myocardial have an acceptable operative risk and
to low transvalvular flow. For the clin- flow reserve than patients with pseudo- AVR may improve long-term survival
ician, the two main questions in low- severe AS (see page 1627).9 Although and functional status in most cases.2 7
gradient, low ejection fraction AS are: these preliminary data are promising, In the recent European guidelines,
How severe is the AS? Which patients can larger studies are necessary to confirm surgery is advised in this group of patients
benefit from surgery? the value of these parameters to distin- with CR.2 Because of the very high
guish these two entities and to determine operative risk in the absence of CR, many
their possible role and feasibility in clinicians consider that the absence of CR
routine clinical practice. The same group constitutes a contraindication to AVR.
Determining the true severity of low-
reported that B-type natriuretic peptide is However, in these patients, the prognosis
gradient, low ejection fraction AS may be
significantly lower, but with a consider- with medical management is extremely
a challenging problem. Physical examina-
able overlap of values, in pseudo-severe poor and there is a trend, in a small
tion is often misleading with a soft
low-gradient, low ejection fraction AS patients series, towards better survival
systolic ejection murmur despite severe
than in true severe AS.10 after AVR.7 Moreover, in those patients
AS. Echocardiography is the key examina-
In true severe low-gradient, low ejec- who survive the perioperative period,
tion for visualising the aortic valve, and
tion fraction AS, the dobutamine-induced functional status improved in more than
measuring the maximum aortic velocity,
increase of SV leads to a marked increase 90% of cases and LVEF improved by
pressure gradient, valve resistance, AVA
of gradient with only a slight change in .10% in more than 60% of cases.4
and EF. As initially reported by deFilippi
AVA.3 6 7 These patients are considered to Perhaps the main determinant for low
have severe low-gradient, low ejection preoperative EF in these patients without
Inserm, ERI 12, Amiens, France and University Hospital fraction AS with CR. In contrast, in some CR is an afterload mismatch that cannot
Amiens, France
patients, dobutamine infusion does not be corrected by inotropic stimula-
Correspondence to: Professor C Tribouilloy,
Department of Cardiovascular Disease, Avenue René
induce any change in SV and conse- tion (dobutamine). Therefore, the
Laënnec, 80054, Amiens Cedex 1, France; tribouilloy. quently no change in gradient or absence of CR with dobutamine in low- AVA.3 6 7 These patients are considered gradient, low ejection fraction AS does

1526 Heart December 2008 Vol 94 No 12


not systematically indicate irreversible AS. For example, patients with low- 4. Quere JP, Monin JL, Levy F, et al.
Influence of preoperative left ventricular contractile
LVD. According to the European guide- gradient, low ejection fraction AS with reserve on postoperative ejection fraction in low-
lines,2 ‘‘surgery can be performed in these an AVA on dobutamine echocardiography gradient aortic stenosis. Circulation
patients but decision-making should take clearly greater than 1.3 cm2 and with 2006;113:1738–44.
into account clinical condition, in parti- 5. Carabello BA, Green LH, Grossman W, et al.
another cause of LVD, such as a large scar Hemodynamic determinants of prognosis of aortic
cular the presence of comorbidity, degree of MI, are not suitable for AVR. However, valve replacement in critical aortic stenosis and
of valve calcification, extent of coronary because the increased afterload due to the advanced congestive heart failure. Circulation
artery disease and feasibility of revascu- ‘‘moderate’’ AS may be not well tolerated 1980;62:42–8.
6. DeFilippi CR, Willett DL, Brickner ME, et al.
larisation’’. Thus the decision for AVR in the presence of a severe associated LVD, Usefulness of dobutamine echocardiography in
surgery should be made case by case and surgery, in our opinion, should be care- distinguishing severe from nonsevere valvular aortic
the absence of CR should not be con- fully discussed in some patients with an stenosis in patients with depressed left ventricular
sidered to be an absolute contraindication function and low transvalvular gradient. Am J Cardiol
AVA of about 1.2–1.3 cm2 on dobuta- 1995;75:191–4.
to AVR. In our opinion, surgery could be mine. Unfortunately, the currently avail- 7. Monin JL, Quere JP, Monchi M, et al. Low-gradient
considered in patients with calcified aortic able data on pseudo-severe AS are too aortic stenosis: operative risk stratification and
valve without CR in the absence of limited to allow any definitive conclu- predictors for long-term outcome: a multicenter study
scarring due to extensive MI and excessive using dobutamine stress hemodynamics. Circulation
sions about the management of these 2003;108:319–24.
comorbidities, and in the presence of a patients, and further multicentre studies 8. Blais C, Burwash I, Mundigler G, et al. Projected
basal mean gradient .20 mm Hg. A heart including larger number of cases are valve area at normal flow rate improves the
transplant should also be considered in assessment of stenosis severity in patients
mandatory in this heterogeneous subset with low-flow, low-gradient aortic stenosis. The
eligible patients. As the currently available of patients. multicentre TOPAS (Truly or Pseudo-Severe
data are unable to identify clearly the Aortic Stenosis) study. Circulation
subset of patient who will have a better Competing interests: None declared. 2006;113:711–21.
outcome with surgery, further studies 9. Burwash IG, Lortie M, Pibarot P, et al. Myocardial
Heart 2008;94:1526–1527. blood flow in patients with low-flow, low-gradient
must be conducted in large series of doi:10.1136/hrt.2008.142745 aortic stenosis. Differences between true and pseudo-
patients with low-gradient, low ejection severe aortic stenosis. Results from the multicentre
fraction AS without CR. In the near TOPAS (Truly or Pseudo-Severe Aortic Stenosis) study
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Heart December 2008 Vol 94 No 12 1527

Assessment and management of
low-gradient, low ejection fraction aortic
Christophe Tribouilloy and Franck Lévy

Heart 2008 94: 1526-1527 originally published online July 31, 2008
doi: 10.1136/hrt.2008.142745

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