Low flow low gradient aortic stenosis resident survival guide: Difference between revisions

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==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:

  1. An aortic valve areas < 1.0 cm2, and
  2. A left ventricular ejection fraction < 40%[1] ( 30% in other references),[2] and
  3. 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. 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.
  2. 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.