Paradoxical Low-flow Aortic Stenosis Research Articles

Low Relative Valve Load is Associated With Paradoxical Low-Flow Aortic Stenosis Despite Preserved Left Ventricular Ejection Fraction and Adverse Clinical Outcomes

Paradoxical low-flow (LF) severe aortic stenosis (AS) despite preserved left ventricular (LV) ejection fraction (LVEF) has been shown to be distinct from normal-flow (NF) AS, with a poorer prognosis. Relative valve load (RVL) is a novel echocardiographic haemodynamic index based on the ratio of transaortic mean pressure gradient to the global valvulo-arterial impedance (Zva) in order to estimate the contribution of the valvular afterload to the global LV load. We aimed to determine the usefulness of RVL in LF AS versus NF AS. A total of 450 consecutive patients with medically managed severe AS (aortic valve area <1.0 cm2) with preserved LVEF (>50%) were studied. Patients were divided into LF (stroke volume index <35 mL/m2) or NF, and high RVL or low RVL. Baseline clinical and echocardiographic profiles, as well as clinical outcomes, were compared. There were 149 (33.1%) patients with LF. Despite higher global impedance in LF (Zva 6.3±2.4 vs 3.9±0.9 mmHg/mL/m2; p<0.001) compared with NF, the RVL in LF AS was significantly lower (5.4±2.7 vs 9.8±5.1 mL/m2; p<0.001). On multivariable analysis, low RVL (≤7.51) remained independently associated with poor clinical outcomes on Cox regression (hazard ratio, 1.31; 95% confidence interval, 1.03-1.68), with 53.2% sensitivity and 70.3% specificity. This was comparable to other prognostic indices in AS. Kaplan-Meier curves demonstrated that low RVL was associated with increased mortality. Increased systemic arterial afterload may be important in the pathophysiology of LF AS. Low RVL was an independent predictor of poor clinical outcomes in medically managed severe AS. There may be a greater role in the attenuation of systemic arterial afterload in AS to improve outcomes.

New Insight in the Assessment of Left Ventricular Function in Paradoxical Low Flow Aortic Stenosis Patients with Normal Left Ventricular Ejection Fraction: A Mini-Review

Paradoxical valvular aortic stenosis (VAS) is a challenging area of clinical cardiology for the practitioners. It involves a small aortic valve area, low flow rate and mean pressure gradient although there is normal left ventricular ejection fraction. The aim of this study was to assess left ventricular (LV) dysfunction in a symptomatic severe aortic valve stenosis which is of crucial importance in identifying patients at risk of heart failure, postoperative complications and increased mortality. There are new insights which are involved in assessment of LV myocardial function including global longitudinal strain (GLS) by two-dimensional speckle tracking echocardiography (2D STE), myocardial performance index (MPI) and maximum rate of LV pressure rise (+dP/dt) during isovolumetric contraction time of the LV. This information can provide both diagnostic and prognostic information in addition to standard echocardiographic and clinical parameters. However, a profound understanding of the complex interaction between loading conditions, chamber geometry and contractility is necessary for the correct interpretation of myocardial deformation in order to draw appropriate conclusions in patients with aortic valve disease. This mini review is related to new and novel insights into the assessment of left ventricular function (LVF) in paradoxical low flow aortic stenosis patients with normal left ventricular ejection fraction (LVEF).

Clinical and echocardiographic features of paradoxical low-flow and normal-flow severe aortic stenosis patients with concomitant mitral regurgitation.

Mitral regurgitation (MR) coexists in a significant proportion of patients with severe aortic stenosis (AS), and portends inferior therapeutic outcomes. In severe AS, MR is thought to contribute to a low-flow state by decreasing forward stroke volume. We investigated concomitant MR on the clinical and echocardiographic features of patients with "paradoxical" low-flow (PLF) and normal-flow (NF) severe AS. Clinical and echocardiographic profiles of 886 consecutive patients with index echocardiographic diagnosis of severe AS (AVA < 1.0cm2) were analysed retrospectively. All patients had preserved ejection fraction (LVEF ≥50%, n = 645), and were divided into PLF (stroke volume index, SVI < 35mL/m2) and NF AS. They were then further subdivided based on the presence or absence of moderate-or-severe MR (msMR). A higher prevalence of concomitant msMR was observed in patients with PLF AS (14.9%; n = 33/221) compared to those with NF AS (8.0%; n = 34/424). Concomitant msMR was associated with echocardiographic features of increased diastolic dysfunction in both PLF AS and NF AS patients, as evidenced by increased LA diameter (PLF AS 52.9 ± 12.5 to 43.9 ± 8.9mm; NF AS 29.6 ± 10.8 to 42.4 ± 8.8mm; p < 0.001) and increased transmitral E/A ratio (PLF AS 1.26 ± 0.56 to 0.92 ± 0.43; NF AS 1.19 ± 0.63 to 0.94 ± 0.45; p = 0.004). Amongst patients with NF AS, msMR was additionally associated with increased E:e' ratio (25.5 ± 15.1 vs 19.3 ± 10.8; p = 0.025). Concomitant MR was more common in PLF AS compared to NF. Although possibly related to the MR, patients severe AS and MR appeared to have more severe diastolic dysfunction. Further studies are warranted to evaluate prognosis and guide management.

IMPACT OF SEX AND LOW-FLOW ON SURVIVAL AFTER AORTIC VALVE REPLACEMENT FOR SEVERE AORTIC STENOSIS AND PRESERVED LEFT VENTRICULAR EJECTION FRACTION

Little is known about sex-related differences amongst patients with paradoxical low-flow aortic stenosis (PLF AS). Objective: to examine whether there is a difference between women and men regarding the impact on outcomes and threshold of low-flow.

Paradoxical low-flow aortic stenosis - baseline characteristics, impact on mortality.

IntroductionParadoxical low-flow, low-gradient aortic stenosis (pLF-LGAS) constitutes an important part of the population undergoing transcatheter aortic valve implantation (TAVI). However, it remains the least defined subtype of aortic stenosis (AS).AimTo investigate baseline characteristics and impact on mortality of pLF-LGAS in patients treated with TAVI.Material and methodsTwo-hundred and thirty-one consecutive patients (mean aortic valve area: 0.76 ±0.41 cm2) who underwent TAVI in our centre during the period of 6 years were included in the study. Based on echocardiographic examination, patients with pLF-LGAS were identified, analysed and compared to a population with high-gradient AS (HGAS) and low-flow, low-gradient AS with reduced ejection fraction (classical, cLF-LGAS). The primary endpoints of the study were all-cause mortality after 30 days and 1 year.ResultspLF-LGAS was diagnosed in 42 (18.2%) patients, whereas 40 (17.3%) had cLF-LGAS and 149 (64.5%) had HGAS. The pLF-LGAS population was younger, had higher prevalence of hypertension, and had higher ejection fraction (EF) than the HGAS population, and had a smaller proportion of heavily symptomatic patients than the cLF-LGAS population. Overall, 46 (19.9%) patients died within 12 months after TAVI. The 30-day and 1-year survival was comparable between AS subtypes. Multivariate analysis identified severe renal failure as an independent predictor of mortality among all patients.ConclusionspLF-LGAS is common among subjects undergoing TAVI. Patients with paradoxical AS are younger, more often burdened with hypertension and have higher EF than the HGAS population, while being less symptomatic than the cLF-LGAS group. Presence of pLF-LGAS does not seem to affect short- and mid-term survival. Severe renal failure is an independent predictor of mortality after TAVI.

Hypertrophic Left Ventricle With Small Cavity and Severe Aortic Angulation: A Dangerous Association in Case of Transcatheter Aortic Valve Replacement

An 87-year-old woman presented with worsening symptoms of heart failure. Echocardiography revealed paradoxical low-flow aortic stenosis (mean gradient 34 mm Hg; aortic valve area 0.9 cm2, indexed stroke volume 31 ml/m2) together with small left ventricular (LV) cavity and septal hypertrophy. The

Right Ventricular Function Is Associated with Left Ventricular Stroke Volume in Patients with Severe Aortic Stenosis and Preserved Ejection Fraction.

A subset of patients with severe aortic stenosis (AS) have lower stroke volumes and valve gradients despite a normal left ventricular ejection fraction (LVEF), referred to as paradoxical low-flow AS (PLF AS). However, the role of right ventricular (RV) function in patients with severe AS and preserved LVEF is not known. We hypothesized that right ventricular function is associated with left ventricular stroke volume in patients with severe AS and preserved LVEF. From an echocardiographic database, we retrospectively identified 102 patients with an indexed aortic valve area ≤0.6cm(2) /m(2) and LVEF≥50%. We used univariate and multivariate linear regression analysis to assess the association between aortic valve stroke volume index (SVi) and right ventricular systolic function as measured by tricuspid annular plane systolic excursion (TAPSE) and by right ventricular fractional area change (FAC). Our population was 98% male with mean age 77.4±9.3years and mean SVi of 36.1±7.9 mL/m(2) . Forty-four patients (43%) met criteria for PLF AS. TAPSE and FAC were positively associated with SVi in both univariate and multivariate regression analysis after correcting for left ventricular variables (β coefficient - TAPSE (cm): 4.59±1.3, P=0.001; FAC (%): 0.19±0.08, P=0.014). Additionally, PLF AS patients had significantly lower mean TAPSE and lower mean FAC when compared dichotomously to normal flow AS patients (P<0.05). Right ventricular systolic function assessed by TAPSE and FAC is significantly related to aortic valve flow in patients with severe AS and preserved LVEF.

Paradoxical low-flow aortic stenosis is defined by increased ventricular hydraulic load and reduced longitudinal strain.

Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. This study investigates the relationship of systolic loading and strain to PLF-AS to further define its pathophysiology. One hundred and twenty patients (age 79 ± 12 years, 37% men) with an indexed aortic valve area (AVAi) of 0.6 cm/m or less and an ejection fraction of 50% or higher were divided into two groups based on indexed stroke volume (SVi): PLF-AS, SVi ≤ 35 ml/m, N = 46; normal-flow aortic stenosis, SVi > 35 ml/m, N = 74). Valvular and arterial load were assessed using multiple measurements, and strain was assessed using speckle-tracking echocardiography. Patients with PLF-AS were found to have more valvular load (lower AVAi, P = 0.028; lower energy loss coefficient, P = 0.001), more arterial load [decreased arterial compliance and increased systemic vascular resistance (SVR), both P < 0.001] and more total hydraulic load [increased valvuloarterial impedance (Zva), P < 0.001]. Transvalvular gradients and arterial pressures were similar. Longitudinal strain was lower in PLF-AS (P < 0.001), but circumferential and rotation strains were similar. On adjusted regression, AVAi, SVR and longitudinal strain were associated with PLF-AS [odds ratio (OR) = 1.34, P = 0.043; OR = 1.31, P = 0.004; OR = 1.34, P = 0.011, respectively]. When SVR and AVAi were replaced with Zva, longitudinal strain and Zva (OR = 1.38, P = 0.015; OR = 1.33, P < 0.001 for both, respectively) were associated with PLF-AS. Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.

Impact of Classic and Paradoxical Low Flow on Survival After Aortic Valve Replacement for Severe Aortic Stenosis

BackgroundLow flow (LF) can occur with reduced (classic) or preserved (paradoxical) left ventricular ejection fraction (LVEF). ObjectivesThe objective of this study was to compare outcomes of patients with low ejection fraction (LEF), paradoxical low flow (PLF), and normal flow (NF) after aortic valve replacement (AVR). MethodsWe examined 1,154 patients with severe aortic stenosis (AS) who underwent AVR with or without coronary artery bypass grafting. ResultsAmong these patients, 206 (18%) had LEF as defined by LVEF of <50%; 319 (28%) had PLF as defined by LVEF of ≥50% but stroke volume indexed to body surface area (SVi) of ≤35 ml ∙ m−2; and 629 (54%) had NF, as defined by LVEF of ≥50% and SVi of >35 ml ∙ m2. Aortic valve area was lower in low flow/LVEF groups (LEF: 0.71 ± 0.20 cm2 and PLF: 0.65 ± 0.23 cm2 vs. NF: 0.77 ± 0.18 cm2; p < 0.001). The 30-day mortality was higher (p < 0.001) in LEF and PLF groups than in the NF group (6.3% and 6.3% vs. 1.8%, respectively). SVi and PLF group were independent predictors of operative mortality (odds ratio [OR]: 1.18, p < 0.05; and OR: 2.97, p = 0.004; respectively). At 5 years after AVR, overall survival was 72 ± 4% in LEF group, 81 ± 2% in PLF group, and 85 ± 2% in NF group (p < 0.0001). ConclusionsPatients with LEF or PLF AS have a higher operative risk, but pre-operative risk score accounted only for LEF and lower LVEF. Patients with LEF had the worst survival outcome, whereas patients with PLF and normal flow had similar survival rates after AVR. As a major predictor of perioperative mortality, SVi should be integrated in AS patients’ pre-operative evaluation.

Recovery of left ventricular systolic function in different entities of aortic stenosis 12 months after TAVI

Background: TAVI improves prognosis of high-risk patients. However, data concerning the impact of TAVI on regional and global LV mechanics in varying entities of severe AS are sparse, particularly in patients with paradoxical low flow aortic stenosis (PLF) or with reduced Left Ventricular Ejection Fraction (LVEF). This study evaluated the effects of Transcatheter Aortic Valve Implantation (TAVI) on Left Ventricular (LV) mechanics in varying entities of aortic stenosis (AS) 12 months after implantation. Methods: A total of 54 consecutive patients with severe AS (24 with normal LVEF and normal flow, 16 with PLF, and 14 with reduced LVEF) were included. Normal LVEF and normal flow were defined as LVEF ≥ 50% and SVI ≥ 35 ml/m2. Paradoxical low flow was defined as LVEF ≥ 50% and SVI < 35 ml/m2 and patients with reduced LVEF, as LVEF < 50%. Speckle tracking echocardiography was performed before and 12 months after TAVI to determine LV global and regional longitudinal deformation. Results: In three entities of AS, there was significant improvement of global and regional LV longitudinal function (global longitudinal strain: -14.1±3.9% at baseline vs. -16.5±4.0% after TAVI, P < 0.001). Interestingly, the beneficial effects were most pronounced in patients with PLF (-14.0±2.9% vs. -17.0±4.4%, P < 0.031) but was significant in all subgroups: normal EF (-16.1±3.4% vs. -18.1±3.3%, P = 0.012) and reduced EF (-10.5±3.1% vs. -13.5±3.2%, P = 0.026). ![Figure][1] Bull's-eye diagram Conclusion: Regardless of the underlying AS entity, TAVI improves global and regional left ventricular mechanics within 12 months. This improvement is more pronounced in patients with PLF. [1]: pending:yes

Paradoxical Low-Flow Aortic Stenosis May Be Worse Than It Seems

The recognition that some patients with severe aortic stenosis (AS) have lower-than-usual gradients and normal left ventricular ejection fractions

Letter by Dumesnil and Pibarot Regarding Article, “Outcome of Patients With Low-Gradient “Severe” Aortic Stenosis and Preserved Ejection Fraction”

HomeCirculationVol. 124, No. 13Letter by Dumesnil and Pibarot Regarding Article, “Outcome of Patients With Low-Gradient “Severe” Aortic Stenosis and Preserved Ejection Fraction” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Dumesnil and Pibarot Regarding Article, “Outcome of Patients With Low-Gradient “Severe” Aortic Stenosis and Preserved Ejection Fraction” Jean G. Dumesnil, MD, FRCP(C), FACC, FASE and Philippe Pibarot, DVM, PhD, FACC, FAHA, FASE, FESC Jean G. DumesnilJean G. Dumesnil Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute Department of Medicine Laval University Québec, Canada (Dumesnil, Pibarot) Search for more papers by this author and Philippe PibarotPhilippe Pibarot Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute Department of Medicine Laval University Québec, Canada (Dumesnil, Pibarot) Search for more papers by this author Originally published27 Sep 2011https://doi.org/10.1161/CIRCULATIONAHA.111.038497Circulation. 2011;124:e360To the Editor:We read with interest the paper by Jander et al1 reporting that patients with low-gradient severe aortic stenosis (LGSAS) and preserved ejection fraction have an outcome similar to that in patients with moderate aortic stenosis (AS). At first glance, this result is discordant with previous studies reporting the opposite,2–4 and in our opinion, further analysis is warranted. Indeed, the entity originally described as paradoxical low-flow or low-gradient AS2,3 is characterized by higher left ventricular (LV) global hemodynamic load, more severe LV concentric remodeling, smaller LV cavity size, and decreased LV midwall radius shortening, and the low gradient is deemed to be due to a lower LV stroke volume related to a restrictive physiology. The LGSAS patients reported by Jander et al1 do not, however, exhibit these features, and in our opinion, the finding of LGSAS in these cases could rather be due to 1 or more of the following2,3: (1) Small body size, (2) measurement errors, or (3) inconsistent grading due to intrinsic discrepancies in guidelines criteria. Body surface area was smaller in the LGSAS group, and some patients could thus have been misclassified as having severe rather than moderate aortic stenosis because the nonindexed rather than the indexed aortic valve area was used for classification. More noteworthy, however, is that recalculation of stroke volume in the LGSAS group by the 2-dimensional volumetric method (ie, LV end-diastolic volume times LV ejection fraction, using the results given in Table 2 in the article) yields much higher values for stroke volume and aortic valve areas (77 mL, 1.00 cm2, and 0.55 cm2/m2) than those reported in the same table (64 mL, 0.82 cm2, and 0.43 cm2/m2), and conversely, dividing the reported stroke volume by the reported LV end-diastolic volume yields a much lower value for ejection fraction than that reported (56% versus 67%). In our opinion, these discrepancies can likely be explained by measurement errors (underestimation) of stroke volume by Doppler and, in turn, could have resulted in overestimation of AS severity in many patients. This explanation is further buttressed by the results of a previous substudy5 from the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) trial whereby, in the same cohort of patients, Cramariuc et al identified only 100 low-flow patients rather than the 223 reported by Jander et al.1 Stroke volumes in the former study,1 however, were calculated with the Teicholz correction of the cube formula rather than by Doppler, and body surface area was taken into account when defining AS severity. Moreover, the low-flow patients also exhibited the restrictive features usually associated with this condition,2–5 and Cramariuc et al5 acknowledged that paradoxical low-flow AS indeed had important implications with regard to intrinsic LV myocardial function. Hence, we would submit that the report by Jander et al1 helps to advance the healthy debate about the assessment of AS severity, but that their results do not correspond to the entity described as paradoxical low-flow AS. Indeed, this condition should not be considered as benign, because it has repeatedly been shown that these patients are less frequently referred to surgery and have a higher mortality if treated medically rather than surgically.2–4Jean G. Dumesnil, MD, FRCP(C), FACC, FASEPhilippe Pibarot, DVM, PhD, FACC, FAHA, FASE, FESC Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute Department of Medicine Laval University Québec, CanadaDisclosuresNone.

Clinical Challenges in Accurate Assessment of Severe Aortic Stenosis With a Special Focus on Low-Gradient Aortic Stenosis and Normal Ejection Fraction

Aortic stenosis (AS) is one of the most common valvular disorders affecting the aging US population. Although guidelines published by leading cardiac societies outline diagnostic and management strategies for this condition, in daily practice clinicians face dilemmas when trying to confirm the diagnosis of severe AS because of discrepancies in quantitative parameters obtained by echocardiography and cardiac catheterization. More recently, a low-gradient variant of severe AS has been increasingly recognized in the setting of normal ejection fraction. This review focuses on the current clinical challenges of AS diagnosis with a special focus on paradoxical low-flow low-gradient AS in the setting of preserved ejection fraction. We evaluate all aspects of AS quantitation in reference to paradoxical low flow aortic stenosis and discuss newer parameters which may help the clinician reconcile some of the discrepancies of this less understood condition.

520 Utility of stress echocardiography to confirm stenosis severity and predict outcome in patients with low flow, low gradient aortic stenosis and preserved lv ejection fraction

520 Utility of stress echocardiography to confirm stenosis severity and predict outcome in patients with low flow, low gradient aortic stenosis and preserved lv ejection fraction

Deterioration of Myocardial Function in Paradoxical Low-Flow Severe Aortic Stenosis: Two-Dimensional Strain Analysis

The diagnosis and management of paradoxical low-flow (PLF) aortic stenosis (AS) is challenging in clinical practice. In addition, its pathophysiology has not been fully understood. The aim of this study was to test the hypothesis that left ventricular (LV) myocardial function is deteriorated in PLF AS and that it is closely related to global LV afterload. Echocardiographic data from 103 patients with severe AS (aortic valve area < 1.0 cm(2)) with normal LV ejection fractions were prospectively collected. Global longitudinal and circumferential myocardial strain was analyzed using two-dimensional speckle-tracking imaging. PLF AS was defined as a stroke volume index < 35 mL/m(2). Sixteen patients were classified as having PLF AS. Compared with those with normal-flow AS, patients with PLF AS were more likely to have worse functional status (mean New York Heart Association functional class, 2.38 ± 0.70 vs 1.96 ± 0.62; P= .02), worse global longitudinal strain (GLS) (-12.6 ± 4.4% vs -16.4 ± 4.0%, P < .01), lower aortic valve area (0.53 ± 0.15 vs 0.78 ± 0.19 cm(2), P < .01), and higher valvuloarterial impedance (5.62 ± 1.33 vs 3.65 ± 0.83 mm Hg · m(2)/mL, P < .01). GLS showed a significant negative linear relationship with stroke volume index (r= -0.324, P= .001) and a positive relationship with E/E' ratio (r= 0.367, P < .001). Multivariate analysis showed that age (β= 0.08, P= .07) and valvuloarterial impedance (β= 1.54, P < .01) were significant predictors of GLS. GLS is depressed in patients with PLF AS. This implies that subclinical myocardial dysfunction may be more prominent in PLF AS compared with normal-flow AS and suggests the possible diagnostic and prognostic value of two-dimensional global strain in identifying PLF AS. In addition, global LV afterload is an important determinant of myocardial dysfunction in patients with severe AS.

146 Adverse impact of pre-therapeutic gradient on outcome in patients with trans-aortic valve implantation: a monocentric experience

Although trans aortic valve implantation (TAVI) is a promising alternative solution for patients who could not undergo conventional surgery, few data are available regarding post-procedure complications among these fragile subjects. We sought to evaluate the factors associated with adverse outcome in patients with TAVI. Clinical, biological and echocardiographic characteristics of the patients were assessed before implantation. Patients were followed up to 30 days after procedure. Our main primary end-point was the composite of death+stroke+acute pulmonary edema at day 30. Between November 2008 and March 2010, n = 55 patients underwent TAVI in our institution (mean age = 84.4 ± 0.7 y; 40% men; mean STS score = 25.2 ± 1.3; 65% transfemoral). Primary endpoint occured in n = 9 subjects (n = 2 deaths; n = 1 stroke; n = 6 pulmonary edema), who presented a longer inhospital stay (14.4 ± 3.2 vs. 9.2 ± 0.6 days, p = 0.008). Patients experiencing the primary endpoint were comparable to the others in terms of age, gender, renal function, comorbidities, type of percutaneous approach and STS score. The pre-implantation aortic gradient was lower in patients with adverse outcome (35.9 ± 4.0 vs. 55.0 ± 2.9 mmHg, p = 0.007), yet the left ventricle ejection fraction (LVEF/56.4 ± 1.9 vs. 58.4 ± 6.0%, p = 0.7) and effective orifice area (0.43 ± 0.03 vs. 0.37 ± 0.02 cm2/m2, p = 0.12) did not significantly differ between the é groups. Among these patients, n = 7 had LVEF>50%. Receiver operating curve analysis showed a significant relationship between aortic gradient and primary end-point (AUC = 0.82 ± 0.07, p = 0.002). Multivariate analysis identified presence of a low trans-aortic gradient (<40 mmHg) as the sole predictor of primary endpoint (HR = 9.3 [1.9–45.0], p = 0.006). Patients with baseline low trans aortic gradient, as a result of either altered LVEF or paradoxical low flow aortic stenosis syndrome, have a higher incidence of major complications after TAVI and should be identified before procedure.