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Clinical and echocardiographic features of paradoxical low-flow and normal-flow severe aortic stenosis patients with concomitant mitral regurgitation

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Abstract

Mitral regurgitation (MR) coexists in a significant proportion of patients with severe aortic stenosis (AS), and portends inferior therapeutic outcomes. In severe AS, MR is thought to contribute to a low-flow state by decreasing forward stroke volume. We investigated concomitant MR on the clinical and echocardiographic features of patients with “paradoxical” low-flow (PLF) and normal-flow (NF) severe AS. Clinical and echocardiographic profiles of 886 consecutive patients with index echocardiographic diagnosis of severe AS (AVA < 1.0 cm2) were analysed retrospectively. All patients had preserved ejection fraction (LVEF  ≥ 50%, n = 645), and were divided into PLF (stroke volume index, SVI < 35 mL/m2) and NF AS. They were then further subdivided based on the presence or absence of moderate-or-severe MR (msMR). A higher prevalence of concomitant msMR was observed in patients with PLF AS (14.9%; n = 33/221) compared to those with NF AS (8.0%; n = 34/424). Concomitant msMR was associated with echocardiographic features of increased diastolic dysfunction in both PLF AS and NF AS patients, as evidenced by increased LA diameter (PLF AS 52.9 ± 12.5 to 43.9 ± 8.9 mm; NF AS 29.6 ± 10.8 to 42.4 ± 8.8 mm; p < 0.001) and increased transmitral E/A ratio (PLF AS 1.26 ± 0.56 to 0.92 ± 0.43; NF AS 1.19 ± 0.63 to 0.94 ± 0.45; p = 0.004). Amongst patients with NF AS, msMR was additionally associated with increased E:e’ ratio (25.5 ± 15.1 vs 19.3 ± 10.8; p = 0.025). Concomitant MR was more common in PLF AS compared to NF. Although possibly related to the MR, patients severe AS and MR appeared to have more severe diastolic dysfunction. Further studies are warranted to evaluate prognosis and guide management.

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  1. Jinghao Nicholas Ngiam and Nicholas Chew contribute equally to the manuscript.

Authors and Affiliations

  1. Department of Medicine, National University Health System, Singapore, Singapore

    Jinghao Nicholas Ngiam, Nicholas Chew & Benjamin Yong-Qiang Tan

  2. Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Rebecca Teng, William K. F. Kong, Edgar Lik Wui Tay, Tiong-Cheng Yeo & Kian-Keong Poh

  3. Department of Cardiology, Massachusetts General Hospital, Boston, USA

    Jonathan D. Kochav & Stephanie M. Kochav

  4. Department of Cardiology, National University Heart Centre, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 119228, Singapore

    Hui Wen Sim, Ching-Hui Sia, William K. F. Kong, Edgar Lik Wui Tay, Tiong-Cheng Yeo & Kian-Keong Poh

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  1. Jinghao Nicholas Ngiam
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Correspondence to Kian-Keong Poh.

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The approval for this study had been granted by the National Healthcare Group Institutional Review Board prior to its conduct. The study therefore had been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. No patient identifiers were collected, and details that might disclose the identity of the subjects under study should were omitted.

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Ngiam, J.N., Chew, N., Teng, R. et al. Clinical and echocardiographic features of paradoxical low-flow and normal-flow severe aortic stenosis patients with concomitant mitral regurgitation. Int J Cardiovasc Imaging 36, 441–446 (2020). https://doi.org/10.1007/s10554-019-01735-1

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  • DOI: https://doi.org/10.1007/s10554-019-01735-1

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