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Multimodality Imaging for Transcatheter Aortic Valve Replacement pp 129–143Cite as

Low-Flow and Low-Gradient Aortic Stenosis Consideration in the Context of TAVR

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Abstract

Aortic valve replacement (AVR) is the definitive treatment for patients with symptomatic, severe AS, typically defined as aortic valve area <1 cm2 and mean transvalvular gradient >40 mmHg. Surgical AVR is associated with substantial improvement in symptomatic status and increased survival for patient with normal and decreased LV function. In contrast, patients with low-gradient severe AS have considerable increased operative risk and less potential benefit from AVR. Low-gradient AS is generally seen in patients with low EF; however, a significant percentage of patients with severe AS may present with low-gradient despite preserved LVEF (“paradoxical” low-flow and low-gradient stenosis). In patients with low-gradient AS, clarification of disease severity and prediction of outcome are clinically challenging. Dobutamine stress echocardiography can help to distinguish true from pseudo AS, and assessment of LV contractile reserve provides important prognostic data regarding outcome. Patients with low-flow and low-gradient severe AS are characterized by a poor natural prognosis, and therefore AVR should not be withheld. The experience with TAVR in patients with low-flow and low-gradient AS is limited, in particular as a high gradient is typically required for inclusion in clinical trials. However, because TAVR is associated with considerably lower operative risk in comparison to standard surgery, it is intuitive that TAVR may be a promising treatment option for patients with low-flow and low-gradient severe AS.

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Abbreviations

AS:

Aortic stenosis

AVA:

Aortic valve area

CR:

Contractile reserve

DI:

Dimensionless index

DSE:

Dobutamine stress echocardiography

EF:

Ejection fraction

LF:

Low flow

LG:

Low gradient

LV:

Left ventricle/ventricular

LVOT:

Left ventricular outflow tract

SAVR:

Surgical aortic valve replacement

SV:

Stroke volume

TAVR:

Transcatheter aortic valve replacement

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Author information

Authors and Affiliations

  1. Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue/JJ5-208A, Cleveland, OH, 44195, USA

    Alper Ozkan MD

  2. Department of Cardiology, Imaging Institute and Heart and Vascular Institute, Cleveland Clinic, J1-4, Cleveland, OH, 44195, USA

    Paul Schoenhagen MD

Authors
  1. Alper Ozkan MD
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Correspondence to Paul Schoenhagen MD .

Editor information

Editors and Affiliations

  1. NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York, USA

    James K. Min

  2. Departments of Imaging and Medicine, David Geffen UCLA School of Medicine, Cedars-Sinai Medical Center Cedars-Sinai Heart Institute, Los Angeles, California, USA

    Daniel S. Berman

  3. Department of Cardiology, St. Paul’s Hospital, University of British Columbia Department of Radiology, Vancouver, British Columbia, Canada

    Jonathon Leipsic

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Ozkan, A., Schoenhagen, P. (2014). Low-Flow and Low-Gradient Aortic Stenosis Consideration in the Context of TAVR. In: Min, J., Berman, D., Leipsic, J. (eds) Multimodality Imaging for Transcatheter Aortic Valve Replacement. Springer, London. https://doi.org/10.1007/978-1-4471-2798-7_10

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  • DOI: https://doi.org/10.1007/978-1-4471-2798-7_10

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  • Online ISBN: 978-1-4471-2798-7

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