Abstract
This review is devoted to the problem of “classical” low-flow, low-gradient aortic stenosis, its diagnosis, treatment
and prognosis. This group of patients is one of the hardest among all patients with aortic stenosis. This problem is
poorly understood and requires a lot of attention. In recent years, due to various reasons (including the improvement
of diagnostic arsenal), there is a clear increase in the frequency of occurrence of such patients. “Classical” low-flow,
low-gradient aortic stenosis, according to various data, occurs in about 5–10% of patients with severe aortic stenosis.
However, the diagnosis of this pathology is faced with significant difficulties. The main objective of the diagnosis
in this case is the differentiation of the true severe from pseudosevere stenosis of the aortic valve. The purpose of this
review is to show the latest results of researches aimed at analyzing the methods of diagnosis and the effectiveness of
various types of treatment of “classical” low-flow, low-gradient aortic stenosis.
References
- Burakovskiy V.I., Bockeria L.A. (Eds.) Cardiovascularsurgery. Moscow: Meditsina; 1989: 752; 384–6 (in Russ.)
- Bockeria L.A., Skopin I.I., Nikitina T.G. Evaluation ofimmediate results after aortic valve replacement inpatients with aortic stenosis and low left ventricularejection fraction. Creative Cardiology.2009; 2: 48–54(in Russ.).
- Gummert J.F., Funkat A.K., Beckmann A., Ernst M.,
Hekmat K., Beyersdorf F. et al. Cardiac surgery in
Germany during 2010: a report on behalf of the German
Society for Thoracic and Cardiovascular Surgery. Thorac.
Cardiovasc. Surg. 2011; 59 (5): 259–67. DOI: 10.1055/s-0030-1271191
- Stewart B.F., Siscovick D., Lind B.K., Gardin J.M.,
Gottdiener J.S., Smith V.E. et al. Clinical factors associated
with calcific aortic valve disease. J. Am. Coll. Cardiol.
1997; 29: 630. DOI: 10.1016/S0735-1097(96)00563-3
- Akishbaya M.O. Analysis of lonf-term results after surgi-cal correction of aortic stenosis. Russian Journal ofThoracic and Cardiovascular Surgery.2006; 2: 51–5(in Russ.).
- Labartkava L.Z. The first results o assessing the quality oflife of patients after surgical correction of aortic stenosisand concomitant coronary artery disease. In: Procee-dings of 11th All-Russian Congress of cardiovascular sur-geons. Moscow; 2005: 335 (in Russ.)
- Lung B., Baron G., Tornos P., Gohlke-Bärwolf C.,
Butchart E.G., Vahanian A. Valvular heart disease in the
community: a European experience. Curr. Probl. Cardiol.
2007; 32 (11): 609–61. DOI: 10.1016/j.cpcardiol.2007.07.002
- Bonow R.O., Carabello B.A., Chatterjee K., de Leon
A.C. Jr, Faxon D.P., Freed M.D., Gaasch W.H. et al.
2008 focused update incorporated into the ACC/AHA
2006 guidelines 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. J. Am. Coll. Cardiol. 2008;
52: e1–142. DOI: 10.1161/CIRCULATIONAHA.108.190748
- Pibarot P., Clavel M.A. Management of paradoxical lowflow,
low-gradient aortic stenosis: need for an integrated
approach, including assessment of symptoms, hypertension,
and stenosis aeverity. J. Am. Coll. Cardiol. 2015; 65:
1097–735. DOI: 10.1016/j.jacc.2014.10.030
- Pibarot P., Dumesnil J.G. Low-flow, low-gradient aortic
stenosis with normal and depressed left ventricular ejection
fraction. J. Am. Coll. Cardiol. 2012; 60: 1097–735.
DOI: 10.1016/j.jacc.2012.06.051
- Tribouilloy C., Rusinaru D., Marechaux S., Castel A.L.,
Debry N., Maizel J. et al. Low-gradient, low-flow severe
aortic stenosis with preserved left ventricular ejection
fraction: characteristics, outcome, and implications for
surgery. J. Am. Coll. Cardiol. 2015; 65: 55–66. DOI: 10.1016/j.jacc.2014.09.080
- Tribouilloy C., Rusinaru D. Diagnosis of paradoxical
low-flow/low-gradient aortic stenosis: A complex
process. Arch. Cardiovasc. Dis. 2017. DOI: 10.1016/j.acvd.2017.01.003
- Bockeria L.A., Skopin I.I., Muratov R.M. The resultsof aortic valve replacement in patients with aortic steno-sis and left ventricular ejection fraction are less than 45%.Bakoulev Journal for Cardiovascular Diseases.2009;10 (3, appl.): 31 (in Russ.)
- Bockeria L.A., Nikitina T.G., Skopin I.I. Evaluation ofthe long-term results of surgical treatment of patientswith aortic stenosis and reduced left ventricular ejectionfraction. Bakoulev Journal for Cardiovascular Diseases.2009; 10 (6, appl.): 35 (in Russ.)
- Bockeria L.A., Nikitina T.G., Skopin I.I. The resultsof surgical correction of aortic stenosis with low left ven-tricular ejection fraction (LV EF ≤ 35%). BakoulevJournal for Cardiovascular Diseases.2010; 11 (6, appl.):26 (in Russ.).
- Vahanian A., Alfieri O., Andreotti F., Antunes M.J.,
Barón-Esquivias G., Baumgartner H. et al. Guidelines
on the management of valvular heart disease (version
2012): the Joint Task Force on the management of valvular
heart disease of the European Society of Cardiology
(ESC) and the European Association for Cardio-
Thoracic Surgery (EACTS). Eur. Heart J. 2012; 33:
2451–96. DOI: 10.1093/eurheartj/ehs109
- De Filippi C.R., Willett D.L., Brickner E., Appleton
C.P., Yancy C.W., Eichhorn E.J. et al. Usefulness of
dobutamine echocardiography in distinguishing severe
from nonsevere valvular aortic stenosis in patients with
depressed left ventricular function and low transvalvular
gradients. Am. J. Cardiol. 1995; 75: 191–4. DOI: 10.1016/s0002-9149(00)80078-8
- Schwammenthal E., Vered Z., Moshkowitz Y.,
Rabinovwitz B., Ziskind Z., Smolinski A.K. et al.
Dobutamine echocardiography in patients with aortic
stenosis and left ventricular dysfunction: predicting outcome
as a function of management strategy. Chest. 2001;
119: 1766–77. DOI: 10.1378/chest.119.6.1766
- Monin J.L., Quere J.P., Monchi M., Petit H., Baleynaud
S., Chauvel C. et al. Low-gradient aortic stenosis:
operative risk stratification and predictors for long-term
outcome: a multicenter study using dobutamine stress
hemodynamics. Circulation. 2003; 108: 319–24. DOI: 10.1161/01.cir.0000079171.43055.46
- Clavel M.A., Fuchs C., Burwash I.G., Mundigler G.,
Dumesnil J.G., Baumgartner H. et al. Predictors of outcomes
in low-flow, low-gradient aortic stenosis: results of
the multicenter TOPAS Study. Circulation. 2008; 118:
S234–42. DOI: 10.1161/CIRCULATIONAHA.107.757427
- Smith R.L., Larsen D., Crawford M.H., Shively B.K.
Echocardiographic predictors of survival in low gradient
aortic stenosis. Am. J. Cardiol. 2000; 86: 804–7. DOI: 10.1016/s0002-9149(00)01089-4
- Cramariuc D., Cioffi G., Rieck A.E., Devereux R.B.,
Staal E.M., Ray S. et al. Low-flow aortic stenosis in
asymptomatic patients: valvular arterial impedance and
systolic function from the SEAS substudy. J. Am. Coll.
Cardiol. Imaging. 2009; 2: 390–9. DOI: 10.1016/j.jcmg.2008.12.021
- Lancellotti P., Donal E., Magne J., O'Connor K.,
Moonen M.L., Cosyns B. et al. Impact of global left ventricular
afterload on left ventricular function in asymptomatic
severe aortic stenosis: a two-dimensional speckletracking
study. Eur. J. Echocardiogr. 2010; 11: 537–43.
DOI: 10.1093/ejechocard/jeq014
- Orsinelli D.A., Aurigemma G.P., Battista S., Krendel S.,
Gaasch W.H. Left ventricular hypertrophy and mortality
after aortic valve replacement for aortic stenosis. A high
risk subgroup identified by preoperative relative wall
thickness. J. Am. Coll. Cardiol. 1993; 22: 1679–83. DOI: 10.1016/0735-1097(93)90595-r
- Hachicha Z., Dumesnil J.G., Bogaty P., Pibarot P.
Paradoxical low flow, low gradient severe aortic stenosis
despite preserved ejection fraction is associated with
higher afterload and reduced survival. Circulation. 2007;
115: 2856–64. DOI: 10.1161/CIRCULATIONAHA.106.668681
- Blais C., Burwash I.G., Mundigler G., Dumensil J.G.,
Loho N., Rader F. et al. Projected valve area at normal
flow rate improves the assessment of stenosis severity in
patients with low flow, low-gradient aortic stenosis: the
multicenter TOPAS (Truly or Pseudo Severe Aortic
Stenosis) study. Circulation. 2006; 113: 711–21. DOI: 10.1161/CIRCULATIONAHA.105.557678
- Picano E., Pibarot P., Lancellotti P., Monin J.L., Bonow
R.O. The emerging role of exercise testing and stress
echocardiography in valvular heart disease. J. Am. Coll.
Cardiol. 2009; 54: 2251–60. DOI: 10.1016/j.jacc.2009.07.046
- Nishimura R.A., Grantham J.A., Connolly H.M.,
Schaff H.V., Higano S.T., Holmes D.R. Jr. Low-output,
low-gradient aortic stenosis in patients with depressed
left ventricular systolic function: the clinical utility of the
dobutamine challenge in the catheterization laboratory.
Circulation. 2002; 106: 809–13.
- Quere J.P., Monin J.L., Levy F., Petit H., Baleynaud S.,
Chauvel C. et al. Influence of preoperative left ventricular
contractile reserve on postoperative ejection fraction
in low-gradient aortic stenosis. Circulation. 2006; 113:
1738–44. DOI: 10.1161/CIRCULATIONAHA.105.568824
- Levy F., Laurent M., Monin J.L., Maillet J.M., Pasquet
A., Le Tourneau T. et al. Aortic valve replacement
for low-flow/low-gradient aortic stenosis: operative risk
stratification and long-term outcome: a European multicenter
study. J. Am. Coll. Cardiol. 2008; 51: 1466–72.
DOI: 10.1016/j.jacc.2007.10.067
- Dumesnil J.G., Pibarot P. Letter by Dumesnil and
Pibarot regarding article “Outcome of patients with lowgradient
“severe” aortic stenosis and preserved ejection
fraction.” Circulation. 2011; 124: e360. DOI: 10.1161/CIRCULATIONAHA.111.038497
- Bermejo J., Yotti R. Low-gradient aortic valve stenosis.
Value and limitations of dobutamine stress testing. Heart.
2007; 93: 298–302. DOI: 10.1136/hrt.2005.066860
- Bergler-Klein J., Mundigler G., Pibarot P., Burwash
I.G., Dumensil J.G., Blais C. et al. B-type natriuretic
peptide in low-flow, low-gradient aortic
stenosis: relationship to hemodynamics and clinical outcome.
Circulation. 2007; 115: 2848–55. DOI: 10.1161/CIRCULATIONAHA.106.654210
- Connolly H.M., Oh J.K., Schaff H.V., Roger V.L.,
Osborn S.L., Hodge D.O. et al. Severe aortic stenosis
with low transvalvular gradient and severe left ventricular
dysfunction. Result of aortic valve replacement in
52 patients. Circulation. 2000; 101: 1940–6. DOI: 10.1161/ 01.cir.101.16.1940
- Brogan W.C., Grayburn P.A., Lange R.A., Hillis L.D.
Prognosis after valve replacement in patients with severe
aortic stenosis and a low transvalvular pressure gradient.
J. Am. Coll. Cardiol. 1993; 21: 1657–60. DOI: 10.1016/0735-1097(93)90383-c
- Blitz L.R., Gorman M., Herrmann H.C. Results of aortic
valve replacement for aortic stenosis with relatively
low transvalvular pressure gradients. Am. J. Cardiol. 1998;
81: 358–62. DOI: 10.1016/s0002-9149(97)00905-3
- Pai R.G., Varadarajan P., Razzouk A. Survival benefit of
aortic valve replacement in patients with severe aortic
stenosis with low ejection fraction and low gradient with
normal ejection fraction. Ann. Thorac. Surg. 2008; 86:
1781–9. DOI: 10.1016/j.athoracsur.2008.08.008
- Fougéres É., Tribouilloy C., Monchi M., Petit-
Eisenmann H., Baleynaud S., Pasquet A. et al. Outcomes
of pseudosevere aortic stenosis under conservative treatment.
Eur. Heart J. 2012; 33: 2426–33. DOI: 10.1093/eurheartj/ehs176
- Zuppiroli A., Mori F., Olivotto I., Castelli G., Favilli S.,
Dolara A. Therapeutic implications of contractile reserve
elicited by dobutamine echocardiography in symptomatic,
low-gradient aortic stenosis. Ital. Heart J. 2003;
4: 264–70. https://www.ncbi.nlm.nih.gov/pubmed/12784780
- Awtry E., Davidoff R. Low-flow/low-gradient aortic
stenosis. Circulation. 2011; 124: e739–41. DOI: 10.1161/CIRCULATIONAHA.111.075853
- Tribouilloy C., Levy F., Rusinaru D., Gueret P., Petit-
Eisenmann H., Baleynaud S. et al. Outcome after aortic
valve replacement for low-flow/low-gradient aortic
stenosis without contractile reserve on dobutamine stress
echocardiography. J. Am. Coll. Cardiol. 2009; 53:
1865–73. DOI: 10.1016/j.jacc.2009.02.026
- Cueff C., Serfaty J.M., Cimadevilla C., Laissy J.P.,
Himbert D., Tubach F. et al. Measurement of aortic valve
calcification using multislice computed tomography:
correlation with haemodynamic severity of aortic stenosis
and clinical implication for patients with low ejection
fraction. Heart. 2011; 97: 721–6. DOI: 10.1136/hrt.2010.198853
- Minners J., Allgeier M., Gohlke-Baerwolf C., Kienzle
R.P., Neumann F.J., Jander N. Inconsistent grading
of aortic valve stenosis by current guidelines: haemodynamic
studies in patients with apparently normal left ventricular
function. Heart. 2010; 96: 1463–8. DOI: 10.1136/hrt.2009.181982
- Kulik A., Burwash I.G., Kapila V., Mesana T.G.,
Ruel M. Long-term outcomes after valve replacement for
low-gradient aortic stenosis: impact of prosthesis-patient
mismatch. Circulation. 2006; 114: I5553–8. DOI: 10.1161/CIRCULATIONAHA.106.665018
- Blais C., Dumesnil J.G., Baillot R., Simard S., Doyle D.,
Pibarot P. Impact of valve prosthesis-patient mismatch
on short-term mortality after aortic valve replacement.
Circulation. 2003; 108: 983–8. DOI: 10.1161/01.cir.0000085167.67105.32
- Herrmann S., Stork S., Niemann M., Lange V.,
Strotmann J.M., Frantz S., Beer M. et al. Low-gradient
aortic valve stenosis: myocardial fibrosis and its influence
on function and outcome. J. Am. Coll. Cardiol. 2011; 58:
402–12. DOI: 10.1016/j.jacc.2011.02.059
- Weidemann F., Herrmann S., Stork S., Neimann M.,
Frantz S., Lange V. et al. Impact of myocardial fibrosis
in patients with symptomatic severe aortic stenosis.
Circulation. 2009; 120: 577–84. DOI: 10.1161/CIRCULATIONAHA.108.847772
- Azevedo C.F., Nigri M., Higuchi M.L., Pomerantzeff
P.M., Spina G.S., Sampaio R.O. et al. Prognostic
significance of myocardial fibrosis quantification by
histopathology and magnetic resonance imaging in
patients with severe aortic valve disease. J. Am. Coll.
Cardiol. 2010; 56: 278–87. DOI: 10.1016/j.jacc.2009.12.074
- Mewton N., Liu C.Y., Croisille P., Bluemke D.,
Lima J.A.C. Assessment of myocardial fibrosis with cardiovascular
magnetic resonance. J. Am. Coll. Cardiol.
2011; 57: 891–903. DOI: 10.1016/j.jacc.2010.11.013
- Dumesnil J.G., Shoucri R.M., Laurenceau J.L.,
Turcot J. A mathematical model of the dynamic geometry
of the intact left ventricle and its application to clinical
data. Circulation. 1979; 59: 1024–34. DOI: 10.1161/01.cir.59.5.1024
- Clavel M.A., Webb J.G., Rodés-Cabau J., Masson J.B.,
Dumont E., De Larochelliè re R. et al. Comparison
between transcatheter and surgical prosthetic valve implantation
in patients with severe aortic stenosis and reduced
left ventricular ejection fraction. Circulation. 2010;
122: 1928–36. DOI: 10.1161/CIRCULATIONAHA.109. 929893
- Gotzmann M., Lindstaedt M., Bojara W., Ewers A.,
Mugge A. Clinical outcome of transcatheter aortic valve
implantation in patients with low-flow, low gradient aortic
stenosis. Catheter. Cardiovasc. Interv. 2012; 79:
693–701. DOI: 10.1002/ccd.23240
- Ben-Dor I., Maluenda G., Iyasu G.D., Laynez-Carnicero
A., Hauville C., Torguson R. et al. Comparison of
outcome of higher versus lower transvalvular gradients in
patients with severe aortic stenosis and low (<40%) left
ventricular ejection fraction. Am. J. Cardiol. 2012; 109:
1031–7. DOI: 10.1016/j.amjcard.2011.11.041
About the authors
Olamafruz K. Abdulloev, Postgraduate; orcid.org/0000-0002-4462-5462