Normal Echocardiographic Left Ventricular Wall Thickness in Severe Aortic Stenosis

Abstract

To the Editor:We appreciate the positive and supporting comments of Cavalli, Volpi and Maggioni on the malignant subgroup of patients with critical aortic valve stenosis who fail to develop adequate compensatory left ventricular hypertrophy.There are two major points that we would like to re-emphasize from our article. Patients who present with physical exmination and echocardiographic findings of aortic stenosis should be evaluated with the following caution. A patient with critical aortic stenosis and a markedly reduced injection fraction may lack adequate compensatory left ventricular reserve and fail to demonstrate left ventricular hypertrophy. Furthermore, a cardiac Doppler finding of a small peak gradient is not uncommon. It has been our experience that many patients with these findings are thought to have a primary myopathy and are medically treated, only to expire. We certainly agree that, at the least, a noninvasive valve area should be calculated and, in most, cardiac catheterization should be undertaken. Since the mortality in this subgroup of patients with medical management is 100 percent, the only recourse is surgical intervention. Unfortunately, the cardiac surgical results are anecdotal from local community to university. These varying surgical results may be due to aortic stenosis with a mixture of reversible and irreversible myocardial dysfunction. For this reason, we are in agreement with the authors that a multicenter prospective surgical study might help clarify the factors which enter into the true surgical mortality of this interesting subset of patients. To the Editor: We appreciate the positive and supporting comments of Cavalli, Volpi and Maggioni on the malignant subgroup of patients with critical aortic valve stenosis who fail to develop adequate compensatory left ventricular hypertrophy. There are two major points that we would like to re-emphasize from our article. Patients who present with physical exmination and echocardiographic findings of aortic stenosis should be evaluated with the following caution. A patient with critical aortic stenosis and a markedly reduced injection fraction may lack adequate compensatory left ventricular reserve and fail to demonstrate left ventricular hypertrophy. Furthermore, a cardiac Doppler finding of a small peak gradient is not uncommon. It has been our experience that many patients with these findings are thought to have a primary myopathy and are medically treated, only to expire. We certainly agree that, at the least, a noninvasive valve area should be calculated and, in most, cardiac catheterization should be undertaken. Since the mortality in this subgroup of patients with medical management is 100 percent, the only recourse is surgical intervention. Unfortunately, the cardiac surgical results are anecdotal from local community to university. These varying surgical results may be due to aortic stenosis with a mixture of reversible and irreversible myocardial dysfunction. For this reason, we are in agreement with the authors that a multicenter prospective surgical study might help clarify the factors which enter into the true surgical mortality of this interesting subset of patients.