Low-gradient Aortic Valve Stenosis Research Articles

Long-term survival after TAVI in low-flow, low-gradient aortic valve stenosis

Long-term survival after TAVI in low-flow, low-gradient aortic valve stenosis

Impact of Stress Echocardiography on Aortic Valve Stenosis Management.

Rest and stress echocardiography (SE) play a fundamental role in the evaluation of aortic valve stenosis (AS). According to the current guidelines for the echocardiographic evaluation of patients with aortic stenosis, four broad categories can be defined: high-gradient AS (mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, aortic valve area (AVA) ≤ 1 cm2 or indexed AVA ≤ 0.6 cm2/m2); low-flow, low-gradient AS with reduced ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, left ventricle ejection fraction (LVEF) < 50%, stroke volume index (Svi) ≤ 35 mL/m2); low-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, LVEF ≥ 50%, SVi ≤ 35 mL/m2); and normal-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, indexed AVA ≤ 0.6 cm2/m2, LVEF ≥ 50%, SVi > 35 mL/m2). Aortic valve replacement (AVR) is indicated with the onset of symptoms development or LVEF reduction. However, there is often mismatch between resting transthoracic echocardiography findings and patient's symptoms. In these discordant cases, SE and CT calcium scoring are among the indicated methods to guide the management decision making. Additionally, due to the increasing evidence that in asymptomatic severe aortic stenosis an early AVR instead of conservative treatment is associated with better outcomes, SE can help identify those that would benefit from an early AVR by revealing markers of poor prognosis. Low-flow, low-gradient AS represents a challenge both in diagnosis and in therapeutic management. Low-dose dobutamine SE is the recommended method to distinguish true-severe from pseudo-severe stenosis and assess the existence of flow (contractile) reserve to appropriately guide the need for intervention in these patients.

High- versus low-gradient aortic stenosis: Is our evaluation limited by aorto-mitral angle on cardiovascular CT?

BackgroundAccurate assessment of aortic valve (AV) stenosis (AS) on transthoracic echocardiogram is crucial for appropriate clinical management. However, discordance between aortic valve area (AVA) and Doppler can complicate the diagnosis of severe AS in low-gradient (LG) AS phenotypes. MethodsWe reviewed 220 consecutive patients with suspected severe AS and AVA ≤1.0 cm2 on transthoracic echocardiogram who were evaluated for transcatheter AV replacement (TAVR) within a large health system from 2015 to 2019. We compared AV calcium score and aorto-mitral angle (AMA) on 3-chamber views from ECG-gated cardiovascular CT among patients with high-gradient (HG) AS (N = 19), paradoxical low-flow low-gradient (PLFLG) AS (N = 24) and normal-flow low-gradient (NFLG) AS (N = 14). ResultsAll groups had comparable age, comorbidities, and AV calcium scores. Compared to patients with HG AS (mean AMA 120 ± 10°), those with PLFLG AS (104 ± 12°; p < 0.001) and NFLG AS (106 ± 13°; p = 0.008) had narrower mean AMA values on cardiovascular CT. ConclusionLG AS patients have significantly narrower AMA than HG AS patients on cardiovascular CT. Due to difficulty obtaining parallel Doppler alignment, narrower AMA may contribute to AVA-Doppler discordance on echocardiogram. These findings emphasize the need for additional information in the setting of LG AS.

Carotid Duplex Ultrasonography to Assess Severity of Low-Flow Low-Gradient Aortic Stenosis

BackgroundPatients with low-flow, low-gradient aortic valve stenosis constitute a substantial subset of all severe aortic stenosis patients. However, assessment of true severity of these patients can be challenging. In this analysis, we study the utility of the common carotid artery waveforms to distinguish true from pseudo-severe low-flow low-gradient aortic stenosis. MethodsThis is an observational analysis that included patients who underwent a transthoracic echocardiogram (TTE) and duplex carotid ultrasonography (DCUS) and had low-flow, low-gradient aortic stenosis with reduced left ventricular ejection fraction (LVEF) on the index TTE (LVEF <50%, calculated aortic valve area [AVA] of ≤1.0 cm2, mean and peak gradient of <40 and <64 mm Hg, respectively, and stroke volume index <35 mL/m2). Patients were classified as pseudo-severe and true-severe aortic stenosis based on additional subsequent testing. Differences in various TTE and DCUS waveform parameters across the aortic valve and the common carotid artery were compared between the 2 groups. ResultsThe study included 30 patients (60 carotid arteries). Fifteen patients were categorized as pseudo-severe and 15 as true severe aortic stenosis. There were no significant differences in calculated AVA, LVEF, stroke volume/stroke volume index, and Doppler Velocity Index in the 2 groups. Mean and peak gradient were higher in patients with true-severe aortic stenosis. Carotid acceleration time (cAT) was significantly prolonged in patients with true-severe compared with pseudo-severe aortic stenosis. A cAT ≥80 ms was 83.3% sensitive and 83.3% specific for true-severe aortic stenosis. ConclusioncAT acceleration time may be used to distinguish true from pseudo-severe low-flow, low-gradient aortic valve stenosis.

Aortic Valve Calcium Score by Computed Tomography as an Adjunct to Echocardiographic Assessment-A Review of Clinical Utility and Applications.

Aortic valve stenosis (AS) is increasing in prevalence due to the aging population, and severe AS is associated with significant morbidity and mortality. Echocardiography remains the mainstay for the initial detection and diagnosis of AS, as well as for grading of severity. However, there are important subgroups of patients, for example, patients with low-flow low-gradient or paradoxical low-gradient AS, where quantification of severity of AS is challenging by echocardiography and underestimation of severity may delay appropriate management and impart a worse prognosis. Aortic valve calcium score by computed tomography has emerged as a useful clinical diagnostic test that is complimentary to echocardiography, particularly in cases where there may be conflicting data or clinical uncertainty about the degree of AS. In these situations, aortic valve calcium scoring may help re-stratify grading of severity and, therefore, further direct clinical management. This review presents the evolution of aortic valve calcium score by computed tomography, its diagnostic and prognostic value, as well as its utility in clinical care.

TCT-661 Outcomes of Patients With High Gradient and Low-Flow Low-Gradient Aortic Valve Stenosis Undergoing Transcatheter Aortic Valve Implantation: Results From the CENTER2 Collaboration

TCT-661 Outcomes of Patients With High Gradient and Low-Flow Low-Gradient Aortic Valve Stenosis Undergoing Transcatheter Aortic Valve Implantation: Results From the CENTER2 Collaboration

Catheter-Induced Postextrasystolic Potentiation in the Assessment of Severity of Low-Gradient Aortic Valve Stenosis.

Deciphering which patients with low-gradient aortic valve disease have severe stenosis can be difficult. We aimed to correlate the postextrasystolic potentiation (PESP) with dobutamine stress echocardiography and multidetector computed tomography in patients with low-gradient aortic valve stenosis. Patients with an aortic valve area ≤1 cm2 and a mean gradient <40 mm Hg were included. Aortic valve stenosis severity was assessed by a core lab with dobutamine stress echocardiography, followed by a multidetector computed tomography aortic valve score if indeterminate. A premature ventricular contraction was induced by intentional catheter contact with the myocardium within the left ventricle. PESP was calculated as a percent change of pre-to-post mean gradient. Multidetector computed tomography was used to measure the aortic valve calcification score, and subsequently, aortic valve calcification density. Twenty-eight patients (age, 77±10 years; 19 female) were included. Dobutamine stress echocardiography increased mean gradient from baseline of 25±7 mm Hg to 36±11 mm Hg; pre-premature ventricular contraction mean gradient was 25±7 mm Hg and increased to post-premature ventricular contraction mean gradient of 32±10 mm Hg, representing a PESP of 24±11%. A ≥20% in PESP resulted in 100% sensitivity, 77% specificity, 83% positive predictive value, and 100% negative predictive value for diagnosing severe aortic valve stenosis. There was a significant correlation between PESP and projected aortic valve area and aortic valve calcification density (R=-0.64, P=0.0003; R=0.057, P=0.014, respectively). In patients with low-gradient aortic valve stenosis, catheter-induced premature ventricular contractions during cardiac catheterization causing ≥20% PESP has a 100% sensitivity for severe aortic valve stenosis. Validation of this 20% cutoff in larger groups with correlation to clinical end points is required.

Prognostic Impact of the Get-with-the-Guidelines Heart-Failure Risk Score (GWTG-HF) after Transcatheter Aortic Valve Replacement in Patients with Low-Flow–Low-Gradient Aortic Valve Stenosis

This study examined the prognostic value of the get-with-the-guidelines heart-failure risk score (GWTG-HF) on mortality in patients with low-flow-low-gradient aortic valve stenosis (LFLG-AS) after transcatheter aortic valve implantation (TAVI). Data on feasibility of TAVI and mortality prediction in the LFLG-AS population are scarce. Clinical risk assessment in this particular population is difficult, and a score has not yet been established for this purpose. A total of 212 heart failure (HF) patients with real LFLG-AS were enrolled. Patients were classified into low-risk (n = 108), intermediate-risk (n = 90) and high-risk (n = 14) groups calculated by the GWTG-HF score. Clinical outcomes of cardiovascular events according to Valve Academic Research Consortium (VARC-2) recommendations and composite endpoint of death and hospitalization for heart failure (HHF) were assessed at discharge and 1 year of follow-up. Baseline parameters of the groups showed a median age of 81.0 years [77.0; 84.0] (79.0 vs. 82.0 vs. 86.0, respectively p < 0.001), median EuroSCORE II of 6.6 [4.3; 10.7] (5.5 vs. 7.2 vs. 9.1, p = 0.004) and median indexed stroke volume of 26.7 mL/m2 [22.0; 31.0] (28.2 vs. 25.8 vs. 25.0, p = 0.004). The groups significantly differed at follow-up in terms of all-cause mortality (10.2 vs. 21.1 vs. 28.6%; p < 0.035). There was no difference in intrahospital event rate (VARC). Postprocedural mean gradients were lower in high-risk group (7.0 vs. 7.0 vs. 5.0 mmHg, p = 0.011). No differences in postprocedural aortic valve area (1.9 vs. 1.7 vs. 1.9 cm2, p = 0.518) or rate of device failure (5.6 vs. 6.8 vs. 7.7%, p = 0.731) could be observed. After adjustment for known predictors, the GWTG score (HR 1.07 [1.01-1.14], p = 0.030) as well as pacemaker implantation (HR 3.97 [1.34-11.75], p = 0.013) turned out to be possible predictors for mortality. An increase in stroke volume index (SVI) was, in contrast, protective (HR 0.90 [0.83-0.97]; p = 0.006). The GWTG score may predict mortality after TAVI in LFLG-AS HF patients. Interestingly, all groups showed similar intrahospital event and mortality rates, independent of calculated mortality risk. Low SVI and new conduction disturbances associated with PPI after THV implantation had negative impact on mid-term outcome in post-TAVI HF-patients.

Transcatheter Aortic Valve Replacement for Severe Aortic Valve Stenosis: Do Patients Experience Better Quality of Life Regardless of Gradient?

Aortic valve replacement improves survival for patients with low-gradient aortic valve stenosis, but there is a paucity of data on postoperative quality of life for this population. In a single-center retrospective analysis of 304 patients with severe aortic valve stenosis who underwent transcatheter aortic valve replacement, patients were divided into 4 groups based on mean pressure gradient, left ventricular ejection fraction, and stroke volume index. Using the Kansas City Cardiomyopathy Questionnaire-12, quality of life was assessed immediately before and 1 month after transcatheter aortic valve replacement. Most patients in the low-flow, low-gradient group were men; this group had higher relative rates of cardiovascular disease and type 2 diabetes than the paradoxical low-flow, low-gradient group; the normal-flow, low-gradient group; and the high-gradient group. All-cause mortality did not differ significantly among the groups at 1 month after surgery, and all groups experienced a significant improvement in quality-of-life scores after surgery. The mean improvement was 27 points in the low-flow, low-gradient group, 25 points in the paradoxical low-flow, low-gradient group, 30 points in the normal-flow, low-gradient group, and 30 points in the high-gradient group (all P < .001). Quality of life improves significantly across all subgroups of aortic valve stenosis after trans-catheter aortic valve replacement, regardless of flow characteristics or aortic valve gradients.

Prognosis of low-flow low-gradient aortic valve stenosis with atrial fibrillation

Abstract Background Patients with Low-flow low-gradient (LFLG) aortic valve stenosis (AS) have possibly poor prognosis. Recently, it was reported that the LFLG AS patients have similar outcomes compared to high-gradient (HG) patients but worse outcomes compared to the normal-flow low-gradient [NFLG: SVi≥35 ml/m2, mPG &amp;lt;40mmHg] subgroup. The main determinant of LF state in severe AS patients with preserved LVEF are male gender, heart rate, LV volume and atrial fibrillation (AF). However, the relationship between the comorbidity with AF in LFLG AS and the risk of heart failure (HF) remains unclear. Purpose We elucidated about the prognosis of LFLG AS with AF. Methods We included 225 consecutive patients with severe AS (SAS, iAVA&amp;lt;0.6 cm2/m2) from 2013 to 2020. Among these patients, high-gradient SAS [HG-SAS; mean pressure gradient (mPG) ≥40 mmHg, n=88] and LFLG AS [stroke volume index (SVi) ≤35 ml/m2, mPG &amp;lt;40 mmHg, n=82] patients was extracted and the baseline characteristics including the presence or absence of AF were evaluated. The primary endpoint was worsening HF that required unplanned hospitalization or readjustment of HF drug therapy. Results Among patients with HG SAS and LFLG AS, worsening HF was observed in 65 patients. LFLG AS patients exhibited a higher oral rate of renin-angiotensin-system inhibitors (p=0.02). In addition, SVi and E/e' was lower in LFLG AS patients compared with HG SAS [SVi; 29.4 (24.4–34.0) versus 37.7 (28.2–45.3), p&amp;lt;0.0001, E/E'; 16.0 (13.1–21.5) vs 20.9 (16.0–27.4), p=0.002]. There is no differences between 2 groups in AF prevalence. Furthermore, 2 groups were subdivided as follow; HG SAS with AF (n=25), HG SAS without AF (n=63), LFLG AS with AF (n=24), LFLG AS without AF (n=58). The Kaplan Meier curves demonstrated LFLG SAS with AF experienced higher rate of worsening HF compared with HG SAS without AF and equivalent rate of worsening HF compared with HG SAS with AF (log rank, p&amp;lt;0.001). In the Cox hazard analysis among the LFLG AS patients, LFLG AS with paroxysmal AF (pAF, n=12) instead of chronic AF (cAF, n=12) showed a higher risk for worsening HF compared with those without AF (HR 5.0; 95% CI, 1.8–14; p=0.0028, HR 1.9; 95% CI, 0.62–5.8; p=0.26, respectively). Conclusion LFLG AS with AF exhibited a poor prognosis for HF compared with HG SAS without AF and equivalent rate of worsening HF compared with HG SAS with AF. Furthermore, the presence of pAf was associated with an increased risk of HF in patients with LFLF AS. Thus, intervention including drugs and catheter ablation for pAF in LFLG AS patients could lead to prevent worsening clinical outcomes. Funding Acknowledgement Type of funding sources: None.

Arterial Wave Reflection and Aortic Valve Stenosis: Diagnostic Challenges and Prognostic Significance.

IntroductionArterial wave reflection is an important component of the left ventricular afterload, affecting both pressure and flow to the aorta. The aim of the present study was to evaluate the impact of wave reflection on transvalvular pressure gradients (TPG), a key parameter for the evaluation of aortic valve stenosis (AS), as well as its prognostic significance in patients with AS undergoing a transcatheter aortic valve replacement (TAVR).Materials and MethodsThe study population consisted of 351 patients with AS (mean age 84 ± 6 years, 43% males) who underwent a complete hemodynamic evaluation before the TAVR. The baseline assessment included right and left heart catheterization, transthoracic echocardiography, and a thorough evaluation of the left ventricular afterload by means of wave separation analysis. The cohort was divided into quartiles according to the transit time of the backward pressure wave (BWTT). Primary endpoint was all-cause mortality at 1 year.ResultsEarly arrival of the backward pressure wave was related to lower cardiac output (Q1: 3.7 ± 0.9 lt/min vs Q4: 4.4 ± 1.0 lt/min, p < 0.001) and higher aortic systolic blood pressure (Q1: 132 ± 26 mmHg vs Q4: 117 ± 26 mmHg, p < 0.001). TPG was significantly related to the BWTT, patients in the arrival group exhibiting the lowest TPG (mean TPG, Q1: 37.6 ± 12.7 mmHg vs Q4: 44.8 ± 14.7 mmHg, p = 0.005) for the same aortic valve area (AVA) (Q1: 0.58 ± 0.35 cm2 vs 0.61 ± 0.22 cm2, p = 0.303). In multivariate analysis, BWTT remained an independent determinant of mean TPG (beta 0.3, p = 0.002). Moreover, the prevalence of low-flow, low-gradient AS with preserved ejection fraction was higher in patients with early arterial reflection arrival (Q1: 33.3% vs Q4: 14.9%, p = 0.033). Finally, patients with early arrival of the reflected wave (Q1) exhibited higher all-cause mortality at 1 year after the TAVR (unadjusted HR: 2.33, 95% CI: 1.17–4.65, p = 0.016).ConclusionEarly reflected wave arrival to the aortic root is associated with poor prognosis and significant aortic hemodynamic alterations in patients undergoing a TAVR for AS. This is related to a significant decrease in TPG for a given AVA, leading to a possible underestimation of the AS severity.

Low-Gradient Aortic Stenosis; the Diagnostic Dilemma.

ABSTRACTLow-gradient (LG) aortic valve stenosis (AS) constitutes a significant subset among patients with severe aortic stenosis. This entity represents one of the most challenging heart conditions when it comes to diagnosis and management, mainly because of the discrepancy between the small aortic valve area (≤1.0 cm2) that is considered a severe AS, and low mean transvalvular pressure gradient (<40 mmHg), which is one of the criteria for nonsevere AS. LG AS is divided according to transvalvular aortic flow rate into normal-flow LG AS and low-flow LG (LFLG) AS; the latter category can be divided further according to left ventricular ejection fraction (LVEF) into classical LFLG AS if LVEF is depressed or paradoxical LFLG AS if LVEF is preserved. The primary diagnostic challenge in patients with LG AS is to confirm that AS is truly severe and not pseudosevere, which is assessed mainly by either dobutamine stress echocardiography or multidetector computed tomography. The management of symptomatic true severe LG AS is mainly by aortic valve replacement (AVR), whether surgical or transcatheter approach. Patients with LG severe AS have a generally worse prognosis and higher mortality compared with patients with high-gradient severe AS. Despite the survival benefit of AVR in patients with true severe LG AS, these patients have higher surgical risk post-AVR compared with high-gradient AS patients. Early recognition and correct diagnosis of a patient with LG AS is crucial to improve their mortality and morbidity.

Higher Acceleration/Ejection Time Ratio Predicts Impaired Outcome in Aortic Valve Stenosis.

Acceleration time (AT)/ejection time (ET) ratio is a marker of aortic valve stenosis (AS) severity and predicts outcome in moderate-severe AS. We explored the association of increased AT/ET ratio on prognosis in 1530 asymptomatic patients with presumably mild-moderate AS, normal ejection fraction, and without known diabetes or cardiovascular disease. Patients were part of the SEAS study (Simvastatin Ezetimibe Aortic Stenosis). Patients were grouped according to the optimal AT/ET ratio threshold to predict cardiovascular death and heart failure hospitalization. Low-gradient severe AS was identified as combined valve area ≤1.0 cm2 and mean gradient <40 mm Hg. Outcome was assessed in Cox regression analyses, and results are reported as hazard ratio and 95% CI. Higher AT/ET ratio was significantly associated with lower systolic blood pressure, lower left ventricular ejection fraction, lower stress-corrected midwall shortening, low flow, and with higher left ventricular mass and higher peak aortic jet velocity. AT/ET ratio ≥0.32 provided the optimal cutoff for predicting incident cardiovascular death and heart failure hospitalization in the total study sample. In patients with low-gradient severe AS, this threshold was >0.32. AT/ET ratio ≥0.32 had a 79% higher risk of cardiovascular death and heart failure hospitalization (hazard ratio, 1.79 [95% CI, 1.20-2.68]). In patients with low-gradient severe AS, AT/ET ratio >0.32 was associated with a 2-fold higher risk of cardiovascular death and heart failure hospitalization (hazard ratio, 2.15 [95% CI, 1.22-3.77]). In asymptomatic nonsevere AS and low-gradient severe AS, higher AT/ET ratio was associated with increased cardiovascular morbidity and mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00092677.

Stress Aortic Valve Index (SAVI) with Dobutamine for Low-Gradient Aortic Stenosis: A Pilot Study

ABSTRACT Background: Potentially some patients have symptoms that arise from their low-gradient aortic valve stenosis (AS). Comprehensive valve physiology with dobutamine stress remains incompletely characterized in this population. Methods: A cohort of 18 subjects with low-gradient AS underwent graded dobutamine infusion with invasive assessment using 0.014” pressure wires. A subset of 4 subjects received thermodilution cardiac output assessment at each stage. Results: Peak dobutamine hemodynamics could not be predicted from clinical or baseline parameters, reflecting statistically the physiologic heterogeneity of the measured pressure loss versus flow curves. While 0 subjects had a baseline aortic/left ventricular pressure ratio during ejection <0.71, 7 of 18 subjects (39%) achieved a ratio during peak dobutamine (the so-called stress aortic valve index, SAVI) below this threshold derived from a prior study of patients undergoing routine transcatheter aortic valve implantation (TAVI). Conclusion: For low-gradient AS, the hemodynamic changes from resting to peak dobutamine conditions cannot be predicted in advance due to pressure loss versus flow curve heterogeneity. A sizable minority of low-gradient AS reaches a severity during dobutamine stress equivalent to patients undergoing TAVI for established benefit. Whether this subset receives similar clinical advantage remains an unproven but natural hypothesis raised by our study.

P1537 Myocardial work in patients with aortic stenosis before and short term after transcatheter aortic valve replacement

Abstract Objective The newly introduced noninvasive myocardial work analysis could potentially be beneficial in predicting the best timing for aortic valve replacement as well as clinical outcomes in patients with high grade aortic valve stenosis (AS), which is the leading valvular disease in the modern aging society. However, to date there is little data on the applicability of the method in the setting of extremely increased left ventricular (LV) afterload. Purpose In this pilot study, we aimed to apply myocardial work analysis in patients with increased LV afterload due to severe AS and to investigate the differences of myocardial work parameters in patients with different AS entities. In addition, we analyzed the early changes of myocardial work after the afterload reduction by transcatheter aortic valve replacement (TAVR). Methods We retrospectively studied echocardiographic data of 28 consecutive patients with severe AS before and 7 days after TAVR. Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE) were calculated using commercially available software based on noninvasive pressure-strain loops. In order to correct for underestimation of intraventricular pressure, we added the mean aortic valve pressure gradient to the peripheral systolic blood pressure used by the software. Results From the included patients (mean age 76 ± 10 years) 13 were classified as having normal flow (NF) severe AS, 8 had low flow low gradient (LFLG) and 7 paradoxical low flow low gradient (PLFLG) AS. GWI and GCW were significantly lower in patients with LFLG AS compared to patients with NF or PLFLG AS (936 ± 528 mmHg% vs. 2493 ± 485 mmHg% vs. 1959 ± 469 mmHg% [p &amp;lt; 0.005] and 1132 ± 477 mmHg% vs. 2770 ± 507 mmHg% vs. 2189 ± 603 mmHg%, [p &amp;lt; 0.005], respectively). 7 days after TAVR, GCW and GWI decreased significantly in patients with NF AS. In other AS entities, a trend towards increased GWI and GCW was observed, but the difference did not reach statistical significance. GWI and GCW remained significantly lower in LFLG AS group when compared to NF and PLFLG groups (1069 ± 378 mmHg% vs. 1919 ± 310 mmHg% vs. 2064 ± 842 mmHg% [p &amp;lt; 0.005] and 1286 ± 346 mmHg% vs. 2107 ± 258 mmHg% vs. 2227 ± 949 mmHg% [p &amp;lt; 0.005]) early after TAVR. GWE and GWW did not differ between the groups and were not influenced by TAVR. Conclusion In this pilot study we applied the adapted myocardial work analysis in patients with increased afterload due to severe AS. We have shown that GCW and GWI are significantly higher in patients with NF AS when compared to LFLG and PLFLG AS. The differences between the groups persisted early after TAVR in spite of significant reduction of GWI and GWC in patients with NF AS. The clinical and prognostic importance of these findings are still to be investigated in a bigger cohort study.

TCT-147 Stress Aortic Valve Index (SAVI) With Dobutamine for Low-Gradient Aortic Stenosis

Potentially some patients have symptoms that arise from their low-gradient aortic valve stenosis (AS) but are not selected for transcatheter aortic valve replacement (TAVR) treatment yet. Comprehensive valve physiology with dobutamine stress remains incompletely characterized in this population.

Clinical Advances in Aortic Diseases: from Aortic Valve to Bifurcation

There is growing understanding to recognize the aorta as complex system and treat aortic diseases in an integrated fashion.The indication for interventional aortic valve replacement (TAVR) comprises patients with moderate and high perioperative risk and symptomatic, high grade aortic valve stenosis. In contrast "low risk" patients receive conventional therapy. Ongoing randomised trials analyse the expansion of indication towards low risk patients for interventional approaches. A final rating is owing, but first data support the assumption that both therapeutic options may be equivalent. Moreover, the interventional therapy of low flow, low gradient aortic valve stenosis has been revalued and interventional valve-in-valve therapy has been integrated into clinical routine as invidualised decision of the heart team.Aortic diseases include several entities which require specialised diagnostic and therapeutic tools. Studies to evaluate evidence of follow up options need to be performed in future to enable for surveillance tailored to suit medical need.

Value of low-dose dobutamine stress echocardiography on defining true severe low gradient aortic stenosis in patients with preserved left ventricular ejection fraction

Low-dose dobutamine stress echocardiography (DSE) is a valuable tool to distinguish true-severe (TS) from pseudo-severe (PS) low gradient aortic valve stenosis (LGAS) in patients with reduced left ventricular ejection fraction (LVEF). However, only scanty studies reported the clinical utility of DSE in differentiating TS-LGAS patients with preserved LVEF. We investigated the clinical utility of DSE in LGAS patients with preserved LVEF and the echocardiographic determinants suggestive of TS-LGAS. 130 consecutive LGAS patients [indexed aortic valve area (AVA) ≤ 0.6cm2/m2 and mean trans-aortic pressure gradient (PGmean) < 40mmHg] with preserved (≥ 50%, n = 63) and reduced (< 50%, n = 67) LVEF were included. DSE defined TS-LGAS (projected AVA ≤ 1 cm2) in 61.2% patients with reduced LVEF and in 68.3% patients with preserved LVEF. Multivariate logistic regression analysis showed that baseline AVA was an independent determinant of TS-LGAS both in LVEF ≥ 50% (OR 0.45, P = 0.004) and LVEF < 50% groups (OR 0.55, P = 0.005). Reduced septal and lateral mitral annular plane systolic excursion (MAPSE, OR 0.72 and 0.75, P = 0.013 and 0.016) and septal TDI-s´ were significantly associated with TS-LGAS in patients with LVEF ≥ 50%. Higher systolic pulmonary artery pressure (SPAP, OR 1.43, P = 0.045) was associated with TS-LGAS in patients with LVEF < 50%. DSE is useful to define TS-LGAS also in patients with preserved LVEF. Lower baseline AVA values are linked with TS-LGAS in both patients with reduced and preserved LVEF. Reduced MAPSE and septal TDI-s´ are suggestive of TS-LGAS in patients with preserved LVEF, while higher SPAP is associated with TS-LGAS in patients with reduced LVEF.

3941Worse outcome of patients with normal ejection fraction but low-gradient aortic valve stenosis after transcatheter aortic valve implantation (TAVI)

3941Worse outcome of patients with normal ejection fraction but low-gradient aortic valve stenosis after transcatheter aortic valve implantation (TAVI)

P1638Impact of left ventricular and aortic valve characteristics on one-year mortality of patients with low-flow low-gradient aortic valve stenosis after transcatheter aortic valve implantation (TAVI)

P1638Impact of left ventricular and aortic valve characteristics on one-year mortality of patients with low-flow low-gradient aortic valve stenosis after transcatheter aortic valve implantation (TAVI)