ECHO 2013 / Aortic Stenosis Quantitation It’s Not All About the Gradient
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Risk stratification in AS: Importance of Valvular, Arterial and Ventricular Interplay
163 asymptomatic patients with severe AS
HR= 1.7, p=0.027
Peak aortic velocity ≥ 4.4 m.s-1
HR= 1.9, p=0.013 Zva ≥ 4.9 mmHg.ml-1.m-2 
HR= 2.2, p=0.003
Longitudinal strain ≤ 15.9 %
HR= 2.8, p=0.001
Ind. LA area ≥ 12.2 cm2/m2
0 1 2 3 4 5 6
Lancellotti et al. Heart 2010 |
Hazard-ratio |
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Severe Aortic Stenosis
VPeak>4 m/s
Mean gradient >40 mm Hg AVA < 1.0 cm²
Re-evaluation Undergoing CABG or
other heart surgery?
Symptoms?
Yes |
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Equivocal |
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No |
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Normal |
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Exercise test |
LV ejection fraction |
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Symptoms |
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BP |
<50% |
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Normal |
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(ESC) |
(ACC/AHA) |
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Yes
Class I |
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Class I |
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Class IIb |
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Class I |
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Class IIa |
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Class IIb |
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Very severe AS (<0.6 cm2)
Severe valve calcification (≥3/4) Rapid progression (≥0.3 m /s/yr)
High Zva (<4.5)
Reduced GLS (<15%)
No
Aortic Valve Replacement |
Clinical/ echo follow-up, |
Wait for symptoms
Preoperative coronary angiography
Low-Flow, Low-Gradient AS
NORMAL-LVEF |
NORMAL-LVEF |
LOW-LVEF |
NORMAL-FLOW |
«PARADOXICAL» |
«CLASSICAL» |
HIGH-GRADIENT |
LOW-FLOW |
LOW-FLOW |
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LOW-GRADIENT |
LOW-GRADIENT |
50-70% |
10-25% |
5-10% |
Case #1
Pibarot & Dumesnil
JACC, in press
LVEF≤40%
P<40
AVA≤1.0
Dobutamine-Stress Echo
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SV ≥ 20 % |
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SV < 20 % |
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Contractile (Flow) Reserve |
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No Contractile (Flow) Reserve |
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AS Severity: |
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Indeterminate |
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P≥40 |
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P<40 |
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AVA<1.0-1.2 |
AVA ≥1.0-1.2 |
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MSCT: Ca Score ≥1650? |
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No |
Yes |
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True-Severe AS |
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Pseudo-Severe AS |
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True-Severe AS |
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SAVR CABG |
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MEDICAL Rx TRIAL |
SAVR (High Op. Risk) |
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TAVR? |
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2012 ESC/EACTS Guidelines on Management
of VHD: Indications for AVR in AS
Vahanian et al. EHJ 2012
“Paradoxical” Low-Flow,
Low-Gradient AS with
Preserved LVEF
↑Age
Women Hypertension MetS – Diabetes
Hachicha Z et al., Circulation, 2007
Dumesnil et al. Eur Heart J, 2009 Pibarot & Dumesnil JACC, 2012
Doppler-Echo Features of Paradoxical
Low-Flow, Low-Gradient AS
The Aortic Valve:
AVA< 1.0 cm2 AVAi < 0.6 cm2/m2 DVI<0.25
Severely thickened/calcified valve
Mean gradient <40 mmHg
Valvulo-arterial impedance > 4.5
The Left Ventricle
EDD<47 mm EDV< 55 mL/m2
RWT ratio > 0.50
Myocardial fibrosis
Impaired LV filling
LVEF > 50%
GLS < 15%
SVi < 35 mL/m2
Pibarot & Dumesnil, JACC 58;413-415, 2011
Hachicha Z et al., Circulation. 115:2856-2864, 2007
Impact of AVR on Survival in Patients with Paradoxical Low-Flow, Low-Gradient AS
Clavel MA
JACC in press
Tarantini et al. Ann Thorac Surg, 91:1808 –15, 2011
Clavel et al. JACC 2012
Results
KM mortality for LF vs NF
Definitions
Low flow (LF) : SVI ≤ 35 mL/m²
Low ejection fraction (LEF): LV EF ≤ 50% Low gradient (LG): Mean gradient ≤ 40 mmHg
ITT - Cohorts A & B
2-Yr Death (%)
ITT - Cohorts A & B
80% |
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LF LEF |
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HR: 1.07 [95% CI: 0.83, 1.37] |
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Log-Rank p= 0.616 |
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70% |
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LF NEF |
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60% |
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50% |
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48.9% |
40% |
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46.1% |
30% |
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20% |
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10% |
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0% |
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0 |
4 |
8 |
12 |
16 |
20 |
24 |
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70% |
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LF (Low Flow) |
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HR: 1.52 [95% CI: 1.24, 1.87] |
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Log-Rank p= <.001 |
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60% |
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NF (Normal Flow) |
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(%) |
50% |
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47.2% |
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Death |
30% |
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40% |
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2-Yr |
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33.9% |
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20% |
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10% |
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0% |
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0 |
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4 |
8 |
12 |
16 |
20 |
24 |
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Numbers at Risk |
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Months |
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LF |
530 |
422 |
368 |
336 |
308 |
282 |
235 |
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NF |
441 |
368 |
342 |
317 |
300 |
274 |
239 |
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Herrmann et al TCT 2012
Numbers at Risk |
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Months |
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LF LEF LG |
225 |
177 |
154 |
142 |
128 |
119 |
100 |
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NF LEF NG |
304 |
214 |
213 |
193 |
179 |
162 |
134 |
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ITT - Cohorts A & B |
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HR: 0.97 [95% CI: 0.65, 1.44] |
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(%) |
70% |
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LF LEF LG |
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Log-Rank p= 0.886 |
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60% |
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LF LEF NG |
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50.9% |
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Death |
50% |
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40% |
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48.0% |
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30% |
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Yr |
20% |
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10% |
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2- |
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0% |
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0 |
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4 |
8 |
12 |
16 |
20 |
24 |
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Numbers at Risk |
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Months |
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LF LEF LG |
147 |
115 |
100 |
94 |
83 |
76 |
67 |
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NF LEF NG |
78 |
62 |
54 |
48 |
45 |
43 |
33 |
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