Clinical manifestations and diagnosis of low gradient severe aortic stenosis
- Dania Mohty, MD, PhD
Dania Mohty, MD, PhD
- Professor of Cardiology
- CHU Limoges, Limoges
Degenerative valvular heart disease (VHD) is common and is the third most frequent cause of cardiac disease after hypertension and coronary artery disease in developed countries with aging populations. Among patients with at least moderate VHD in developed countries, aortic valve stenosis (AS) is most common, followed by mitral regurgitation then aortic regurgitation and finally mitral stenosis .
For appropriate diagnosis and management of AS, it is crucial to assess the severity of AS as accurately as possible. However, the diagnosis and evaluation of AS is challenging due to a variety of pitfalls. These include discrepancies between severity of AS and patient symptoms, between transvalvular mean pressure gradient and aortic valve area, and between echocardiography and other imaging modalities. In addition, a number of confounding factors and technical issues affect the assessment of AS, including the presence of concurrent conditions such as uncontrolled hypertension, rapid atrial fibrillation, left ventricular dysfunction, and significant mitral regurgitation or stenosis, as well as the occurrence of measurement errors.
Issues relating to the clinical manifestations and diagnosis of low gradient AS will be reviewed here. Management and prognosis of low gradient severe AS, and the clinical presentation and management of classical high gradient severe AS are discussed separately. (See "Clinical manifestations and diagnosis of aortic stenosis in adults" and "Medical management of asymptomatic aortic stenosis in adults" and "Indications for valve replacement in aortic stenosis in adults", section on 'Low gradient aortic stenosis' and "Management and prognosis of low gradient aortic stenosis".)
DEFINITIONS AND CLASSIFICATION
High gradient severe AS — The 2014 American Heart Association/American College of Cardiology valvular heart disease guidelines identify severe aortic stenosis (AS) by the presence of an aortic transvalvular velocity ≥4 m/s and/or mean transvalvular pressure gradient ≥40 mmHg; the aortic valve area (AVA) is typically ≤1 cm2 (with AVA indexed to body surface area ≤0.6 cm2/m2), although it may be larger with concurrent AS and aortic regurgitation (table 1) ; similar criteria are included in the 2012 European Society of Cardiology valve disease guidelines . However, these high velocity and high pressure gradient criteria are valid only in the presence of a normal stroke volume. At least 50 percent of patients with symptomatic severe AS have high-gradient AS.
Types of low flow and/or low gradient AS — Low flow (stroke volume indexed to body surface area ≤35mL/m2) severe AS and low gradient (transvalvular mean pressure gradient ≤40 mmHg) severe AS are partially overlapping categories of AS:
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- DEFINITIONS AND CLASSIFICATION
- High gradient severe AS
- Types of low flow and/or low gradient AS
- Categories of low gradient severe AS
- True severe versus pseudo-severe AS
- CAUSES AND PATHOPHYSIOLOGY
- CLINICAL MANIFESTATIONS
- Clinical characteristics
- Symptoms and signs
- Initial tests
- DIAGNOSIS AND EVALUATION
- Initial approach to diagnosis
- - When and how to diagnose AS
- - When to suspect low gradient AS
- Additional evaluation based upon type of low gradient AS
- - Approach to classical low flow, low gradient AS
- - Approach to paradoxical low flow, low gradient AS
- - Approach to normal flow, low gradient AS
- Diagnostic tests
- - Key tests
- Resting transthoracic echocardiogram
- Low-dose dobutamine stress echocardiogram
- Multidetector computed tomography
- Projected aortic valve area
- - Additional tests
- Transesophageal echocardiography
- Cardiac catheterization
- - Investigational tests
- Natriuretic peptides
- Measures of longitudinal LV systolic function
- DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS