Low flow low gradient aortic stenosis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]


When severe systolic and/or diastolic myocardial dysfunction coexist with aortic stenosis, there is a decrease in the flow through the valve leading to a prominent decrease in the transvalvular gradient, a condition referred to as low flow low gradient aortic stenosis (LF-LG AS). LF-LG AS with is defined as:

  1. An aortic valve areas < 1.0 cm2, and
  2. A mean pressure difference or gradient across the aortic valve of < 40 mm Hg


Shown below is an algorithm of the management of low flow, low gradient aortic stenosis.[1]

Abbreviations: AVR: Aortic valve replacement; EOA: Effective orifice area; ΔPmean: mean pressure gradient

Ultrasound evaluation of aortic stenosis
Effective orifice area (EOA)≤ 1 cm2
Pressure gradient (ΔP)<40 mmHg
Low grade low flow aortic stenosis
Normal left ventricular ejection fraction
Left ventricular ejection fraction≤ 40-50%[2]
No specific recommendations:
- Surgical AVR, or
- Transcather AVR, or
- Medical treatment
Dobutamine stress test
Increase in stroke volume by ≥ 20%
Increase in stroke volume by <20%
Presence of left ventricular flow reserve
Absence of left ventricular flow reserve
True severe aortic stenosis
Pseudo-severe aortic stenosis
True severe aortic stenosis
Surgical AVR
with/without CABG
Medical treatment
Close follow up
Transcather AVR


  1. Pibarot P, Dumesnil JG (2012). "Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction". J Am Coll Cardiol. 60 (19): 1845–53. doi:10.1016/j.jacc.2012.06.051. PMID 23062546.
  2. Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.