Low flow low gradient aortic stenosis resident survival guide: Difference between revisions
Jump to navigation
Jump to search
Rim Halaby (talk | contribs) |
Rim Halaby (talk | contribs) |
||
Line 3: | Line 3: | ||
==Definition== | ==Definition== | ||
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). | 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 low LVEF is defined as: | ||
#An [[aortic valve area|aortic valve areas]] < 1.0 cm<sup>2</sup>, and | |||
#A [[ejection fraction|left ventricular ejection fraction]] < 40%<ref name="pmid23062546">{{cite journal| author=Pibarot P, Dumesnil JG| title=Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 19 | pages= 1845-53 | pmid=23062546 | doi=10.1016/j.jacc.2012.06.051 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23062546 }} </ref> ( 30% in other references),<ref name="pmid10779460">{{cite journal| author=Connolly HM, Oh JK, Schaff HV, Roger VL, Osborn SL, Hodge DO et al.| title=Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction:result of aortic valve replacement in 52 patients. | journal=Circulation | year= 2000 | volume= 101 | issue= 16 | pages= 1940-6 | pmid=10779460 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10779460 }} </ref> and | |||
#A [[Intravascular pressure gradient|mean pressure difference or gradient]] across the aortic valve of < 30 mm Hg | |||
*When low flow low gradient aortic stenosis is present, the challenge is to determine whether the LF-LG AS with low LVEF is a true severe aortic stenosis or a pseudo-severe aortic stenosis. It is very important to differentiate these two entities as they have different outcomes following aortic valve replacement.<ref name="pmid23062546">{{cite journal| author=Pibarot P, Dumesnil JG| title=Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 19 | pages= 1845-53 | pmid=23062546 | doi=10.1016/j.jacc.2012.06.051 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23062546 }} </ref> | |||
==Management== | ==Management== |
Revision as of 14:02, 6 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Definition
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 low LVEF is defined as:
- An aortic valve areas < 1.0 cm2, and
- A left ventricular ejection fraction < 40%[1] ( 30% in other references),[2] and
- A mean pressure difference or gradient across the aortic valve of < 30 mm Hg
- When low flow low gradient aortic stenosis is present, the challenge is to determine whether the LF-LG AS with low LVEF is a true severe aortic stenosis or a pseudo-severe aortic stenosis. It is very important to differentiate these two entities as they have different outcomes following aortic valve replacement.[1]
Management
Shown below is an algorithm of the management of low flow, low gradient aortic stenosis.[1]
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% | ||||||||||||||||||||||
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 | ||||||||||||||||||||||
ΔP≥40 EOA<1-1.2 | ΔP<40 EOA≥1-1.2 | EOA<1-1.2 | |||||||||||||||||||||
True severe aortic stenosis | Pseudo-severe aortic stenosis | True severe aortic stenosis | |||||||||||||||||||||
Surgical AVR with/without CABG | Medical treatment Close follow up | Transcather AVR | |||||||||||||||||||||
References
- ↑ 1.0 1.1 1.2 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.
- ↑ Connolly HM, Oh JK, Schaff HV, Roger VL, Osborn SL, Hodge DO; et al. (2000). "Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction:result of aortic valve replacement in 52 patients". Circulation. 101 (16): 1940–6. PMID 10779460.