Aortic Stenosis

Abstract

Severe symptomatic aortic stenosis (AS) is a lethal disease, the only effective therapy for which is mechanical relief of the obstruction to outflow, ie, aortic valve replacement (AVR). Generally held tenets about AS include the following. (1) Patients with preserved systolic function have an excellent outcome after AVR.1 (2) Patients with reduced ejection fraction (EF) and high afterload also have an excellent response to AVR because AVR reduces afterload and allows ejection performance to return toward normal.2,3 (3) Patients with low flow, reduced EF, and pseudo-AS would not benefit from AVR. Pseudo-AS has been defined as a condition in which calculated aortic valve area falsely overestimates the severity of AS when aortic valve area is calculated at low flow.4,5 Because in such cases the AS is in fact not severe, it has been reasoned that AVR would not be of benefit. (4) Patients with truly severe AS, low EF, and low gradient benefit from AVR when such patients demonstrate inotropic reserve.6 (5) Even some low-EF, low-gradient patients without inotropic reserve benefit from AVR.7 However, 2 studies of AS published in this issue of Circulation raise many interesting questions about our management of patients with AS.8,9 These studies help to confirm some of our concepts of managing this disease while raising questions about others. Articles pp 2848 and 2856 The study by Hachicha et al8 seems to confirm at least 1 of the aforementioned concepts: that AS patients with only mild left ventricular (LV) systolic dysfunction have an excellent outcome after AVR. Their group of patients with impaired mid-wall shortening and reduced forward stroke volume, …