Low flow low gradient aortic stenosis resident survival guide: Difference between revisions
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==Overview== | ==Overview== | ||
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 | 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: | ||
#An [[aortic valve area|aortic valve areas]] < 1.0 cm<sup>2</sup>, and | #An [[aortic valve area|aortic valve areas]] < 1.0 cm<sup>2</sup>, and | ||
#A [[Intravascular pressure gradient|mean pressure difference or gradient]] across the aortic valve of < 40 mm Hg | |||
#A [[Intravascular pressure gradient|mean pressure difference or gradient]] across the aortic valve of < | |||
==Management== | ==Management== | ||
Shown below is an algorithm of the management of low flow, low gradient aortic stenosis.<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> | Shown below is an algorithm of the management of low flow, low gradient aortic stenosis.<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> | ||
<span style="font-size:85%">'''Abbreviations:''' '''AVR:''' [[Aortic valve replacement]]; '''EOA:''' Effective orifice area; '''ΔP<sub>mean</sub>:''' mean pressure gradient</span> | |||
{{familytree/start}} | {{familytree/start}} | ||
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{{familytree | | | B01 | | | | | boxstyle=background: WhiteSmoke| B01= '''Low grade low flow aortic stenosis'''}} | {{familytree | | | B01 | | | | | boxstyle=background: WhiteSmoke| B01= '''Low grade low flow aortic stenosis'''}} | ||
{{familytree | |,|-|^|-|.| | | | | }} | {{familytree | |,|-|^|-|.| | | | | }} | ||
{{familytree | C01 | | C02 | | | boxstyle=background: WhiteSmoke| C01= Normal left ventricular ejection fraction| C02= Left ventricular ejection fraction≤ 40%}} | {{familytree | C01 | | C02 | | | boxstyle=background: WhiteSmoke| C01= Normal left ventricular ejection fraction| C02= Left ventricular ejection fraction≤ 40-50%<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>}} | ||
{{familytree | |!| | | |!| | | | }} | {{familytree | |!| | | |!| | | | }} | ||
{{familytree | C03 | | |!| | | | boxstyle=background: LightSkyBlue| C03= '''No specific recommendations:''' <br>'''- Surgical [[aortic valve replacement|AVR]], or''' <br>'''- Transcather AVR, or''' <br> '''- Medical treatment'''}} | {{familytree | C03 | | |!| | | | boxstyle=background: LightSkyBlue| C03= '''No specific recommendations:''' <br>'''- Surgical [[aortic valve replacement|AVR]], or''' <br>'''- Transcather AVR, or''' <br> '''- Medical treatment'''}} | ||
Latest revision as of 11:40, 19 July 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
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:
- An aortic valve areas < 1.0 cm2, and
- A mean pressure difference or gradient across the aortic valve of < 40 mm Hg
Management
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 | ||||||||||||||||||||||
| 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
- ↑ 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.
- ↑ 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.