Management and prognosis of low gradient aortic stenosis
- Dania Mohty, MD, PhD
Dania Mohty, MD, PhD
- Professor of Cardiology
- CHU Limoges, Limoges
- Section Editors
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
- Stephen JD Brecker, MD, FRCP, FESC, FACC
Stephen JD Brecker, MD, FRCP, FESC, FACC
- Section Editor — Valvular and Aortic Disease
- Chief of Cardiology
- Clinical Academic Group
- St. George's Hospital & University of London
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 accurately as possible. However, the diagnosis and evaluation of AS are challenging due to a variety of pitfalls.
The management and prognosis of low gradient AS will be reviewed here. Clinical manifestations and diagnosis of low gradient AS and the clinical presentation and treatment of high gradient severe AS are discussed separately. (See "Clinical manifestations and diagnosis of low gradient severe aortic stenosis" and "Clinical manifestations and diagnosis of aortic stenosis in adults" and "Medical management of symptomatic aortic stenosis" 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'.)
Approach to management — Management of patients with low gradient aortic stenosis AS starts with confirming the severity and type of AS. Subsequent steps include referral of patients with symptomatic true severe AS to a heart valve team for possible aortic valve replacement, monitoring asymptomatic patients, preventive measures to reduce risk of decompensation, and pharmacologic therapy to treat risk factors in asymptomatic patients and as a temporizing or palliative measure in symptomatic patients.
Confirmation of AS severity and type — Key steps in the management of patients with low gradient AS are to confirm the AS severity and type (see "Clinical manifestations and diagnosis of low gradient severe aortic stenosis", section on 'Diagnosis and evaluation'):
- Iung B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J 2003; 24:1231.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:2438.
- Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
- Monin JL, Quéré JP, Monchi M, et al. Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics. Circulation 2003; 108:319.
- Pereira JJ, Lauer MS, Bashir M, et al. Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction. J Am Coll Cardiol 2002; 39:1356.
- Connolly HM, Oh JK, Schaff HV, et al. Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction:result of aortic valve replacement in 52 patients. Circulation 2000; 101:1940.
- Dayan V, Vignolo G, Magne J, et al. Outcome and Impact of Aortic Valve Replacement in Patients With Preserved LVEF and Low-Gradient Aortic Stenosis. J Am Coll Cardiol 2015; 66:2594.
- Clavel MA, Pibarot P. Assessment of low-flow, low-gradient aortic stenosis: multimodality imaging is the key to success. EuroIntervention 2014; 10 Suppl U:U52.
- Tribouilloy C, Rusinaru D, Maréchaux S, et al. Low-gradient, low-flow severe aortic stenosis with preserved left ventricular ejection fraction: characteristics, outcome, and implications for surgery. J Am Coll Cardiol 2015; 65:55.
- Kang DH, Jang JY, Park SJ, et al. Watchful observation versus early aortic valve replacement for symptomatic patients with normal flow, low-gradient severe aortic stenosis. Heart 2015; 101:1375.
- Debry N, Sudre A, Amr G, et al. Transcatheter aortic valve implantation for paradoxical low-flow low-gradient aortic stenosis patients. Catheter Cardiovasc Interv 2016; 87:797.
- Conrotto F, D'Ascenzo F, D'Amico M, et al. Outcomes of patients with low-pressure aortic gradient undergoing transcatheter aortic valve implantation: A Meta-analysis. Catheter Cardiovasc Interv 2016.
- Herrmann HC, Pibarot P, Hueter I, et al. Predictors of mortality and outcomes of therapy in low-flow severe aortic stenosis: a Placement of Aortic Transcatheter Valves (PARTNER) trial analysis. Circulation 2013; 127:2316.
- Quere JP, Monin JL, Levy F, et al. Influence of preoperative left ventricular contractile reserve on postoperative ejection fraction in low-gradient aortic stenosis. Circulation 2006; 113:1738.
- Nishimura RA, Grantham JA, Connolly HM, et al. Low-output, low-gradient aortic stenosis in patients with depressed left ventricular systolic function: the clinical utility of the dobutamine challenge in the catheterization laboratory. Circulation 2002; 106:809.
- Lange RA, Hillis LD. Dobutamine stress echocardiography in patients with low-gradient aortic stenosis. Circulation 2006; 113:1718.
- Bergler-Klein J, Mundigler G, Pibarot P, et al. B-type natriuretic peptide in low-flow, low-gradient aortic stenosis: relationship to hemodynamics and clinical outcome: results from the Multicenter Truly or Pseudo-Severe Aortic Stenosis (TOPAS) study. Circulation 2007; 115:2848.
- Herrmann S, Störk S, Niemann M, et al. Low-gradient aortic valve stenosis myocardial fibrosis and its influence on function and outcome. J Am Coll Cardiol 2011; 58:402.
- Weidemann F, Herrmann S, Störk S, et al. Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis. Circulation 2009; 120:577.
- Fougères E, Tribouilloy C, Monchi M, et al. Outcomes of pseudo-severe aortic stenosis under conservative treatment. Eur Heart J 2012; 33:2426.
- Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 2007; 115:2856.
- Brogan WC 3rd, Grayburn PA, Lange RA, Hillis LD. Prognosis after valve replacement in patients with severe aortic stenosis and a low transvalvular pressure gradient. J Am Coll Cardiol 1993; 21:1657.
- Carabello BA, Green LH, Grossman W, et al. Hemodynamic determinants of prognosis of aortic valve replacement in critical aortic stenosis and advanced congestive heart failure. Circulation 1980; 62:42.
- Lopez-Marco A, Miller H, Youhana A, et al. Low-flow low-gradient aortic stenosis: surgical outcomes and mid-term results after isolated aortic valve replacement. Eur J Cardiothorac Surg 2016; 49:1685.
- Blitz LR, Gorman M, Herrmann HC. Results of aortic valve replacement for aortic stenosis with relatively low transvalvular pressure gradients. Am J Cardiol 1998; 81:358.
- Lund O. Preoperative risk evaluation and stratification of long-term survival after valve replacement for aortic stenosis. Reasons for earlier operative intervention. Circulation 1990; 82:124.
- Approach to management
- Confirmation of AS severity and type
- Choice of therapy
- - Indications for referral to heart valve team
- - Evidence on the impact of aortic valve replacement
- For classical low flow low gradient AS
- For paradoxical low flow low gradient AS
- For normal flow low gradient AS
- - Evidence on the impact of transcatheter aortic valve implantation
- Evaluation of potential candidates for aortic valve replacement
- - Referral to heart valve team
- - Investigational pre-procedural tests
- Contractile reserve as a prognostic indicator
- Natriuretic peptides
- Measures of systolic function
- Role of palliative care
- General management
- Pharmacologic therapy
- - For patients with pseudo-severe AS
- - For patients with true severe AS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS