The Functional Significance of Paradoxical Low-Gradient Aortic Valve Stenosis

• Published in: JACC. Cardiovascular imaging Vol. 10; no. 1; pp. 29 - 39
• Main Authors: Pérez del Villar, Candelas, Yotti, Raquel, Espinosa, María Ángeles, Gutiérrez-Ibañes, Enrique, Barrio, Alicia, Lorenzo, María José, Sánchez Fernández, Pedro Luis, Benito, Yolanda, Prieto, Raquel, Pérez David, Esther, Martínez-Legazpi, Pablo, Fernández-Avilés, Francisco, Bermejo, Javier
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.01.2017
• Subjects: aortic valve stenosis; Cardiovascular; hemodynamics; vascular function; SBP; vascular function; SvO2; SV; SVI; aortic valve stenosis; PCWP; LV; AVA; hemodynamics; AS; SACI; SAC; PLGAS; VO2; MG; SVRI; systemic arterial compliance index; systolic blood pressure; stroke volume index; paradoxical low-gradient aortic stenosis; aortic stenosis; left ventricular; VO 2; systemic arterial compliance; oxygen uptake; pulmonary capillary wedge pressure; mixed venous oxygen saturation; stroke volume; systemic vascular resistance index; mean transvalvular pressure gradient; SvO 2; aortic valve area
• ISSN: 1936-878X; 1876-7591
• DOI: 10.1016/j.jcmg.2016.03.018

The goal of this study was to determine the functional impact of paradoxical low-gradient aortic stenosis (PLGAS) and clarify whether the relevance of the valvular obstruction is related to baseline flow. Establishing the significance of PLGAS is particularly challenging. Twenty symptomatic patients (77 ± 6 years of age; 17 female subjects) with PLGAS (mean gradient 28 ± 6 mm Hg; aortic valve area 0.8 ± 0.1 cm2; ejection fraction 66 ± 7%) underwent cardiopulmonary exercise testing combined with right-heart catheterization and Doppler echocardiographic measurements. Aortic valve area increased by 84 ± 23% (p < 0.001) and, in 70% of subjects, it reached values >1.0 cm2 at peak exercise. Stroke volume index and blood pressure increased by 83 ± 56% and 26 ± 16%, respectively (both p < 0.0001). Peak oxygen consumption inversely correlated with the rate of increase in pulmonary capillary wedge pressure (PCWP) (PCWP slope: R = –0.61; p = 0.004). In turn, the PCWP slope was determined by changes in the valvular and vascular load but not by the rest of the indices of aortic stenosis. The functional impact of PLGAS was also not related to baseline flow. Agreement between Doppler echocardiography and the Fick technique was good up to intermediate workload. In symptomatic patients with PLGAS, the capacity to dynamically reduce vascular and valvular loads determines the effect of exercise on PCWP, which, in turn, conditions the functional status. A critically fixed valvular obstruction may not be the main mechanism of functional impairment in a large proportion of patients with PLGAS. Exercise echocardiography is suitable to study the dynamics of PLGAS. [Display omitted]