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Severe low-gradient aortic stenosis: impact of inadequate left ventricular responses to high afterload on diagnosis and therapeutic decision-making

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Abstract

The fact that nearly 50% of patients with an aortic valve (AV) area < 1.0 cm2, consistent with severe aortic stenosis (AS), can have mean trans-AV pressure gradients < 40 mmHg, consistent with non-severe AS, indicates that “low-gradient” (LG) severe AS, which is often associated with poor prognosis, deserves particular consideration. Inadequate left ventricular (LV) adaptation to severe AV stenosis resulting from preexistent intrinsic myocardial damages and/or maladaptive LV responses to increased afterload are typical features of severe LG-AS. The diagnosis and management of patients with severe LG-AS are particularly challenging because the discrepancy between the AV area and the trans-AV pressure gradient raises doubts concerning the actual severity of AS and therefore also about the necessity of AV replacement (AVR). LG-AS diagnosis requires integrative multimodality evaluation of both the AV and the LV and therapeutic decision-making necessitates careful individual benefit-risk estimation. Although patients with severe LG-AS associated with low trans-AV flow (i.e., stroke volume ≤ 35 ml/m2) have worse outcomes after AVR than those with high-gradient severe AS, even those with reduced LV ejection fraction (LVEF) can have a significant survival benefit particularly by transcatheter AVR. Dobutamine stress echocardiography facilitates distinction between true-severe and pseudo-severe low-flow LG-AS with reduced LVEF. The review aimed to provide an updated theoretical and practical basis for those engaged in this demanding and still current topic due to the new aspects which have emerged in conjunction with both the evolving scientific knowledge about the various LV responses to the increased afterload and the increasing use of the less invasive transcatheter AVR.

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References

  1. Nitta M, Takamoto T, Taniguchi K, Hultgren HN (1988) Diagnostic accuracy of continuous wave Doppler echocardiography in severe aortic stenosis in the elderly. Jpn Heart J 29(2):169–178. https://doi.org/10.1536/ihj.29.169

    Article  CAS  PubMed  Google Scholar 

  2. Connolly HM, Oh JK, Schaff HV et al (2000) Severe aortic stenosis with low transvalvular gradient gradient and severe left ventricular dysfunction: result of aortic valve replacement in 52 patients. Circulation 101(16):1940–1946. https://doi.org/10.1161/01.cir.101.16.1940

    Article  CAS  PubMed  Google Scholar 

  3. Otto CM (2006) Valvular aortic stenosis: disease severity and timing of intervention. Am Coll Cardiol 47(11):2141–2151. https://doi.org/10.1016/j.jacc.2006.03.002

    Article  Google Scholar 

  4. Bonow RO, Carabello BA, Chatterjee K et al (2006) 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 (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Circulation 114(5):e84–e231. https://doi.org/10.1161/CIRCULATIONAHA.106.176857

    Article  PubMed  Google Scholar 

  5. Vannan MA, Tridetti J, Lancellotti P (2020) Intervention in severe aortic stenosis: it may be time when the left ventricle says so. J Am Coll Cardiol 75(19):2459–2462. https://doi.org/10.1016/j.jacc.2020.04.007

    Article  PubMed  Google Scholar 

  6. Clavel MA, Magne J, Pibarot P (2016) Low-gradient aortic stenosis. Eur Heart J. 2016; 37(34):2645–57. https://doi.org/10.1093/eurheartj/ehw096

  7. Hein S, Arnon E, Kostin S et al (2003) Progression from compensated hypertrophy to failure in the pressure-overloaded human heart: structural deterioration and compensatory mechanisms. Circulation 107(7):984–991. https://doi.org/10.1161/01.cir.0000051865.66123.b7

    Article  PubMed  Google Scholar 

  8. Namasivayam M, He W, Churchill TW et al (2020) Transvalvular flow rate determines prognostic value of aortic valve area in aortic stenosis. Am Coll Cardiol 75(15):758–1769. https://doi.org/10.1016/j.jacc.2020.02.046

    Article  Google Scholar 

  9. Rask LP, Karp KH, Eriksson NP (1996) Flow dependence of the aortic valve area in patients with aortic stenosis: assessment by application of the continuity equation. J Am Soc Echocardiogr 9(3):295–299. https://doi.org/10.1016/s0894-7317(96)90143-1

    Article  CAS  PubMed  Google Scholar 

  10. Strange G, Stewart S, Celermajer D et al (2019) Poor long-term survival in patients with moderate aortic stenosis. J Am Coll Cardiol 74(15):1851–1863. https://doi.org/10.1016/j.jacc.2019.08.004

    Article  PubMed  Google Scholar 

  11. Kligfield P, Okin P (1979) Effect of ventricular function on left ventricular ejection time in aortic stenosis. Br Heart J 42(4):438–441. https://doi.org/10.1136/hrt.42.4.438

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Sato K, Kumar A, Jobanputra Y et al (2019) Association of time between left ven-tricular and aortic systolic pressure peaks with severity of aortic stenosis and calcification of aortic valve. JAMA Cardiol 4(6):549–555. https://doi.org/10.1001/jamacardio.2019.1180

    Article  PubMed  PubMed Central  Google Scholar 

  13. Altes A, Sochala M, Attias D et al (2019) Correlates of the ratio of acceleration time to ejection time in patients with aortic stenosis: an echocardiographic and computed tomo-graphy study. Arch Cardiovasc Dis 112(10):567–575. https://doi.org/10.1016/j.acvd.2019.06.004

    Article  PubMed  Google Scholar 

  14. Mancusi C, de Simone G, Brguljan HJ et al (2021) Management of patients with combined arterial hypertension and aortic valve stenosis: a consensus document from the Council on Hypertension and Council on Valvular Heart Disease of the European Society of Cardiology, the European Association of Cardiovascular Imaging (EACVI), and the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J - Cardiovascular Pharmacotherapy 7(3):242–250. https://doi.org/10.1093/ehjcvp/pvaa040

    Article  Google Scholar 

  15. Puls M, Beuthner BE, Topcil R et al (2020) Impact of myocardial fibrosis on left ventricular remodelling, recovery, and outcome after transcatheter aortic valve implanta-tion in different haemodynamic subtypes of severe aortic stenosis. Eur Heart J 41(20):1903–1914. https://doi.org/10.1093/eurheartj/ehaa033

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Vahanian A, Beyersdorf F, Praz F et al (2021) ESC/EACTS guidelines for the manage-ment of valvular heart disease: developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 60(4):727–800. https://doi.org/10.1093/ejcts/ezab389

    Article  PubMed  Google Scholar 

  17. Slimani A, Roy C, de Meester C et al (2021) Structural and functional correlates of gradient-area patterns in severe aortic stenosis and normal ejection fraction. JACC Cardiovasc Imaging 14(3):525–536. https://doi.org/10.1016/j.jcmg.2020.09.031

    Article  PubMed  Google Scholar 

  18. Lancellotti P, Magne J, Donal E et al (2012) Clinical outcome in asymptomatic severe aortic stenosis: insights from the new proposed aortic stenosis grading classification. J Am Coll Cardiol 59(3):235–243. https://doi.org/10.1016/j.jacc.2011.08.072

    Article  CAS  PubMed  Google Scholar 

  19. Otto CM, MD, Nishimura RA, Bonow RO et al (2021) 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation 143(5):e72–e227. https://doi.org/10.1161/CIR.0000000000000923

    Article  PubMed  Google Scholar 

  20. Wani A, Harland DR, Bajwal TK et al (2022) Left ventricular mechanics differ in subtypes of aortic stenosis following transcatheter aortic valve replacement. Front Cardiovasc Med 8:777206. https://doi.org/10.3389/fcvm.2021.777206. eCollection 2021

  21. Bohbot Y, Renard C, Manrique A et al (2020) Usefulness of cardiac magnetic resonance imaging in aortic stenosis. Circ Cardiovasc Imaging. 13(5):e010356:1–16. https://doi.org/10.1161/CIRCIMAGING.119.010356

  22. Guzzetti E, Annabi MS, Pibarot P, Clavel MA (2020) Multimodality imaging for dis-cordant low-gradient aortic stenosis: assessing the valve and the myocardium. Front Cardiovasc Med. Dec 3;7:570689. https://doi.org/10.3389/fcvm.2020.570689. eCollection 2020

  23. Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P (2007) Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 115(22):2856–2864. https://doi.org/10.1161/CIRCULATIONAHA.106.668681

    Article  PubMed  Google Scholar 

  24. Galian L, Evangelista A (2015) Low-gradient severe aortic stenosis with preserved ejection fraction. A aethophysiologic entity or a methodologic disparity?. Rev Esp Cardiol 68(8):649–52. https://doi.org/10.1016/j.rec.2015.04.007

  25. Clavel MA, Dumesnil JG, Capoulade R et al (2012) Outcome of patients with aortic stenosis, small valve area, and low-flow, low-gradient despite preserved left ventricular ejection fraction. J Am Coll Cardiol 60(14):1259–1267. https://doi.org/10.1016/j.jacc.2011.12.054

    Article  PubMed  Google Scholar 

  26. Petrov G, Dworatzek E, Schulze MT, Dandel M et al (2014) Maladaptive remodeling is associated with impaired survival in women but not in men after aortic valve replacement. JACC Cardiovasc Imaging 7(11):1073–1080. https://doi.org/10.1016/j.jcmg.2014.06.017

    Article  PubMed  Google Scholar 

  27. Dumesnil JG, Pibarot P, Carabello B (2010) Paradoxical low flow and/or low gra-dient severe aortic stenosis despite preserved left ventricular ejection fraction: implications for diagnosis and treatment. Eur Heart J 31(3):281–289. https://doi.org/10.1093/eurheartj/ehp361

    Article  PubMed  Google Scholar 

  28. Rizzello V (2021) Moderate gradient severe aortic stenosis: diagnosis, prognosis and therapy. Eur Heart J Suppl 23(Suppl E):E133–E137. https://doi.org/10.1093/eurheartj/suab108

    Article  PubMed  PubMed Central  Google Scholar 

  29. Zusman O, Pressman GS, Banai S et al (2018) Intervention versus observation in symptomatic patients with normal flow-low gradient severe aortic stenosis. JACC Cardiovasc Imaging 11(9):1225–1232. https://doi.org/10.1016/j.jcmg.2017.07.020

    Article  PubMed  Google Scholar 

  30. Chadha G, Bohbot Y, Rusinaru D et al (2019) Outcome of normal-flow low-gradient severe aortic stenosis with preserved left ventricular ejection fraction: a propensity-matched study. J Am Heart Assoc 8(19):e012301. https://doi.org/10.1161/JAHA.119.012301

    Article  PubMed  PubMed Central  Google Scholar 

  31. Dayan V, Vignolo G, Magne J et al (2015) Outcome and impact of aortic valve replace-ment in patients with preserved LV ejection fraction and low gradient aortic stenosis: a meta-analysis. J Am Coll Cardiol 66(23):2594–2603. https://doi.org/10.1016/j.jacc.2015.09.076

    Article  PubMed  Google Scholar 

  32. Baumgartner H, Falk V, Bax JJ et al (2017) 2017 ESC/EACTS guidelines for the man-agement of valvular heart disease. The Task Force for 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 38(36):2739–2791. https://doi.org/10.1093/eurheartj/ehx391

  33. Kawada Y, Kitada S, Hachiya K et al (2021) Left ventricular hypertrophic change indicat-ing poor prognosis in patients with normal-flow, low-gradient severe aortic stenosis with pre-served left ventricular ejection fraction. Circ Rep 3(6):345–353. https://doi.org/10.1253/circrep.CR-21-0011

  34. Ring L, Shah BN, Bhattacharyya S et al (2021) Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography. Echo Res Pract 8(1):G19–59. https://doi.org/10.1530/ERP-20-0035

  35. Pawade T, Sheth T, Guzzetti E et al (2019) Why and how to measure aortic valve calcification in patients with aortic stenosis. JACC Cardiovasc Imaging 12:1835–1848. https://doi.org/10.1016/j.jcmg.2019.01.045

    Article  PubMed  Google Scholar 

  36. Nemchyna O, Knierim J, Dandel M et al (2021) Feasibility of two-dimensional speckle-tracking echocardiography of aortic valve in patients with calcific aortic valve disease. J Biomech 122:110474. https://doi.org/10.1016/j.jbiomech.2021.110474. Online ahead of print

  37. Beneduce A, Capogrosso C, Moroni F et al (2020) Aortic valve area calculation using 3D trans-esophageal echocardiography: implications for aortic stenosis severity grading. Echocardiography 37(12):2071–2081. https://doi.org/10.1111/echo.14883. (Epub 2020 Oct 7)

    Article  PubMed  Google Scholar 

  38. Saikrishnan N, Kumar G, Sawaya FJ et al (2014) Accurate assessment of aortic stenosis: a review of diagnostic modalities and hemodynamics. Circulation 129(2):244–253. https://doi.org/10.1161/CIRCULATIONAHA.113.002310

    Article  PubMed  Google Scholar 

  39. Bonow RO, Carabello BA, Chatterjee K et al (2008) American College of Cardiology/American Heart Association Task Force on practice guidelines. 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 (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease) endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 52(13):e1–142. https://doi.org/10.1016/j.jacc.2008.05.007

  40. Hagendorff A, Knebel F, Helfen A et al (2020) Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation. Clin Res Cardiol 109(3):271–288. https://doi.org/10.1007/s00392-019-01539-2

  41. Cȏté N, Simard L, Zenses A-S et al (2017) Impact of vascular hemodynamics on aortic stenosis evaluation: new insights into the pathophysiology of normal flow-small aortic valve area-low gradient pattern. J Am Heart Assoc 6(7):e006276. https://doi.org/10.1161/JAHA.117.006276

    Article  PubMed  PubMed Central  Google Scholar 

  42. Clavel AM, Malouf J, Messika-Zeitoun D et al (2015) Aortic valve area calculation in aortic stenosis by CT and Doppler echocardiography. JACC Cardiovasc Imaging 8(3):248–257. https://doi.org/10.1016/j.jcmg.2015.01.009

    Article  PubMed  Google Scholar 

  43. Kebed K, Sun D, Addetia K et al (2020) Measurement errors in serial echocardiographic assessments of aortic valve stenosis severity. Int J Cardiovasc Imaging 36(3):471–479. https://doi.org/10.1007/s10554-019-01745-z

    Article  PubMed  Google Scholar 

  44. Rusinaru D, Malaquin D, Marechaux S et al (2015) Relation of dimensionless index to long-term outcome in aortic stenosis with preserved LVEF. JACC Cardiovasc Imaging 8:766–775. https://doi.org/10.1016/j.jcmg.2015.01.023

    Article  PubMed  Google Scholar 

  45. Rafique AM, Buner S, Ray I et al (2009) Meta-analysis of prognostic value of stress testing in patients with asymptomatic severe aortic stenosis. Am J Cardiol 104(7):972–977. https://doi.org/10.1016/j.amjcard.2009.05.044

    Article  PubMed  Google Scholar 

  46. Otto CM, Burwash IG, Legget ME et al (1997) Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation 95:2262–2270. https://doi.org/10.1161/01.cir.95.9.2262

    Article  CAS  PubMed  Google Scholar 

  47. Annabi MS, Touboul E, Dahou A (2018) Dobutamine stress echocardiography for management of low-flow, low-gradient aortic stenosis. JACC 71(5):475–485. https://doi.org/10.1016/j.jacc.2017.11.052

    Article  CAS  PubMed  Google Scholar 

  48. Monin JL, Quéré JP, Monchi M et al (2003) Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics. Circulation 108(3):319–324. https://doi.org/10.1161/01.CIR.0000079171.43055.46

    Article  PubMed  Google Scholar 

  49. Annabi MS, Clavel M-A, Pibarot P (2019) Dobutamine stress echocardiography in low-flow, low-gradient aortic stenosis: flow reserve does not matter anymore. J Am Heart Assoc 8(6):e012212. https://doi.org/10.1161/JAHA.119.012212

    Article  PubMed  PubMed Central  Google Scholar 

  50. Clavel MA, Burwash IG, Mundigler G et al (2010) Validation of conventional and simplified methods to calculate projected valve area at normal flow rate in patients with low flow, low gradient aortic stenosis: the multicenter TOPAS (True or Pseudo Severe Aortic Stenosis) study. J Am Soc Echocardiogr 23(4):380–386. https://doi.org/10.1016/j.echo.2010.02.002

    Article  PubMed  Google Scholar 

  51. Maes F, Lerakis S, Barbosa RH et al (2019) Outcomes from transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis and left ventricular ejection fraction less than 30%: a substudy from the TOPAS-TAVI Registry. JAMA Cardiol 4(1):64–70. https://doi.org/10.1001/jamacardio.2018.4320

    Article  PubMed  Google Scholar 

  52. Pibarot P, Clavel M-A (2015) Management of paradoxical low-flow, low-gradient aortic stenosis: need for an integrated approach, including assessment of symptoms, hypertension, and stenosis severity. J Am Coll Cardiol 65(1):67–71. https://doi.org/10.1016/j.jacc.2014.10.030

    Article  PubMed  Google Scholar 

  53. Rossi A, Nistri S, Cioffi G et al (2013) Severe aortic valve stenosis with normal left ventricular function and low vs. high pressure gradient: different hemodynamic profiles but similar clinical presentation, comorbidity and outcome. Int J Cardiol 167(5):2326–8. https://doi.org/10.1016/j.ijcard.2012.11.013

  54. Dandel M, Hetzer R (2021) Ventricular systolic dysfunction with and without altered myocardial contractility: clinical value of echocardiography for diagnosis and therapeutic decision-making. Int J Cardiol 2021(327):236–250. https://doi.org/10.1016/j.ijcard.2020.11.068

    Article  Google Scholar 

  55. Lancellotti P (2012) Grading aortic stenosis severity when the flow modifies the gradient valve area correlation. Cardiovasc Diagn Ther 2(1):6–9. https://doi.org/10.3978/j.issn.2223-3652.2012.02.03

    Article  PubMed  PubMed Central  Google Scholar 

  56. Potter E, Marwick TH (2018) Assessment of left ventricular function by echocardiography. JACC Cardiovasc Imaging 11(2):260–274. https://doi.org/10.1016/j.jcmg.2017.11.017

    Article  PubMed  Google Scholar 

  57. Gu H, Saeed S, Boguslavskyi A et al (2019) First-phase ejection fraction is a powerful predictor of adverse events in asymptomatic patients with aortic stenosis and preserved total ejection fraction. JACC Cardiovasc Imaging 12(1):52–63. https://doi.org/10.1016/j.jcmg.2018.08.037

    Article  PubMed  Google Scholar 

  58. Hetzer R, Dandel M (2011) Early detection of left ventricular dysfunction in patients with mitral regurgitation due to flail leaflet is still a challenge. Eur Heart J 32(6):665–667. https://doi.org/10.1093/eurheartj/ehq399

    Article  PubMed  Google Scholar 

  59. Lang RM, Badano LP, Mor-Avi V et al (2015) Recommendations for cardiac chamber quan-tification by echocardiography in adults: an update from the American Society of Echocardio-graphy and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28(1):1-39.e14. https://doi.org/10.1016/j.echo.2014.10.003

    Article  PubMed  Google Scholar 

  60. Andersen OS, Smiseth OA, Dokainish H et al (2017) Estimating left ventricular filling pressure by echocardiography. J Am Coll Cardiol 69(15):1937–1948. https://doi.org/10.1016/j.jacc.2017.01.058

    Article  PubMed  Google Scholar 

  61. Anand V, Adigun OR, Thaden TJ et al (2020) Predictive value of left ventricular diastolic chamber stiffness in patients with severe aortic stenosis undergoing aortic valve replacement. Eur Heart J - Cardiovascular Imaging 21(10):1160–1168. https://doi.org/10.1093/ehjci/jez292

    Article  Google Scholar 

  62. Nagueh SF, Smithet OA, Appleton CP et al (2016) Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 17(12):1321–1360. https://doi.org/10.1093/ehjci/jew082

    Article  PubMed  Google Scholar 

  63. Clavel M-A, Messika-Zeitoun D, Pibarot P et al (2013) The complex nature of discordant se-vere calcified aortic valve disease grading: new insights from combined Doppler echocardiographic and computed tomographic study. J Am Coll Cardiol 62(24):2329–2338. https://doi.org/10.1016/j.jacc.2013.08.1621

    Article  CAS  PubMed  Google Scholar 

  64. Vannan MA, Pibarot P, Lancellotti P (2019) Aortic stenosis: the emperor’s new clothes. J Am Coll Cardiol 74(15):1864–1867. https://doi.org/10.1016/j.jacc.2019.08.1029

    Article  PubMed  Google Scholar 

  65. Fougères E, Tribouilloy C, Monchi M et al (2012) Outcomes of pseudo-severe aortic ste-nosis under conservative treatment. Eur Heart J 33(19):2426–2433. https://doi.org/10.1093/eurheartj/ehs176

    Article  PubMed  Google Scholar 

  66. Levy F, Laurent M, Monin JL et al (2008) Aortic valve replacement for low-flow/low-gradient aortic stenosis operative risk stratification and long-term outcome: a European multi-center study. J Am Coll Cardiol 51:1466–1472. https://doi.org/10.1016/j.jacc.2007.10.067

    Article  PubMed  Google Scholar 

  67. Tribouilloy C, Levy F, Rusinaru D et al (2009) Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echo-cardiography. J Am Coll Cardiol 53:1865–1873. https://doi.org/10.1016/j.jacc.2009.02.026

    Article  PubMed  Google Scholar 

  68. Mehrotra P, Jansen K, Flynn AW et al (2013) Differential left ventricular remodelling and longitudinal function distinguishes low flow from normal-flow preserved ejection fraction low-gradient severe aortic stenosis. Eur Heart J 34:1906–1914. https://doi.org/10.1093/eurheartj/eht094

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  69. Jander N, Minners J, Holme I et al (2011) Outcome of patients with low-gradient “severe” aortic stenosis and preserved ejection fraction. Circulation 123(13):887–895. https://doi.org/10.1161/CIRCULATIONAHA.110.979302

    Article  PubMed  Google Scholar 

  70. Petrov G, Regitz-Zagrosek E, Lehmkuhl E, Krabatsch T, Dunkel A, Dandel M et al (2010) Regression of myocardial hypertrophy after aortic valve replacement. Circulation 122(11):S23–S28. https://doi.org/10.1161/CIRCULATIONAHA.109.927764

    Article  PubMed  Google Scholar 

  71. Chieffo A, Giustino G, Spagnolo P et al (2015) Routine screening of coronary artery disease with computed tomographic coronary angiography in place of invasive coronary angiography in patients undergoing transcatheter aortic valve replacement. Circ Cardiovasc Interv 8(7):e002025. https://doi.org/10.1161/CIRCINTERVENTIONS.114.002025

    Article  PubMed  Google Scholar 

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  1. German Centre for Cardiovascular Research (DZHK), partner site Berlin, 13347, Berlin, Germany

    Michael Dandel

  2. Cardio Centrum Berlin, Berlin, Germany

    Michael Dandel & Roland Hetzer

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Dandel, M., Hetzer, R. Severe low-gradient aortic stenosis: impact of inadequate left ventricular responses to high afterload on diagnosis and therapeutic decision-making. Heart Fail Rev 27, 2017–2031 (2022). https://doi.org/10.1007/s10741-022-10240-y

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