Low-flow/low-gradient Aortic Stenosis Without Contractile Reserve-a Case Report

Overview

Journal Eur Heart J Case Rep

Publisher Oxford University Press

Specialty Cardiology & Vascular Diseases

Date 2022 Jul 20

PMID 35854884

Authors

Lukas Stastny

Julia Dumfarth

Guy Friedrich

Nikolaos Bonaros

Affiliations

Soon will be listed here.

Abstract

Background: Diagnosis and management of low-flow/low-gradient aortic stenosis are very challenging. Resting echocardiography is not capable of differentiating between different types and origins of low-flow and low-gradient state in aortic valve stenosis. Therefore, dobutamine stress echocardiography (DSE) and cardiac computed tomography (CCT) are necessary. This case report should illustrate the importance of these assessments.

Case Summary: A 73-year-old woman presented to our emergency department with New York Heart Association III symptoms of exertional dyspnoea. In addition, the patient complained of fatigue and low resilience. On physical examination, auscultation revealed a systolic murmur over the aortic valve. Further diagnostic steps revealed a low-flow/low-gradient aortic valve stenosis (LF/LGAS) without contractile reserve (CR) in DSE and massive valve calcification in CCT.

Discussion: In this case, we demonstrate the importance of different assessments and workflow. The prognosis of LF/LGAS has been re-evaluated during the last decade and the current guidelines recommend the treatment of such patients even in the absence of CR. Furthermore, we are discussing the results of LF/LGAS.

References

Clavel M, Burwash I, Pibarot P . Cardiac Imaging for Assessing Low-Gradient Severe Aortic Stenosis. JACC Cardiovasc Imaging. 2017; 10(2):185-202. DOI: 10.1016/j.jcmg.2017.01.002. View

Tribouilloy C, Levy F, Rusinaru D, Gueret P, Petit-Eisenmann H, Baleynaud S . Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. J Am Coll Cardiol. 2009; 53(20):1865-73. DOI: 10.1016/j.jacc.2009.02.026. View

Monin J, Quere J, Monchi M, Petit H, Baleynaud S, Chauvel C . Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics. Circulation. 2003; 108(3):319-24. DOI: 10.1161/01.CIR.0000079171.43055.46. View

Fougeres E, Tribouilloy C, Monchi M, Petit-Eisenmann H, Baleynaud S, Pasquet A . Outcomes of pseudo-severe aortic stenosis under conservative treatment. Eur Heart J. 2012; 33(19):2426-33. DOI: 10.1093/eurheartj/ehs176. View

Sato K, Sankaramangalam K, Kandregula K, Bullen J, Kapadia S, Krishnaswamy A . Contemporary Outcomes in Low-Gradient Aortic Stenosis Patients Who Underwent Dobutamine Stress Echocardiography. J Am Heart Assoc. 2019; 8(6):e011168. PMC: 6475055. DOI: 10.1161/JAHA.118.011168. View

Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D . Stress Echocardiography Expert Consensus Statement--Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur Heart J. 2008; 30(3):278-89. DOI: 10.1093/eurheartj/ehn492. View

Maes F, Lerakis S, Barbosa Ribeiro H, Gilard M, Cavalcante J, Makkar R . Outcomes From Transcatheter Aortic Valve Replacement in Patients With Low-Flow, Low-Gradient Aortic Stenosis and Left Ventricular Ejection Fraction Less Than 30%: A Substudy From the TOPAS-TAVI Registry. JAMA Cardiol. 2018; 4(1):64-70. PMC: 6439680. DOI: 10.1001/jamacardio.2018.4320. View

Cueff C, Serfaty J, Cimadevilla C, Laissy J, Himbert D, Tubach F . Measurement of aortic valve calcification using multislice computed tomography: correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction. Heart. 2010; 97(9):721-6. DOI: 10.1136/hrt.2010.198853. View

Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J . 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2021; 43(7):561-632. DOI: 10.1093/eurheartj/ehab395. View

10.

Levy F, Laurent M, Monin J, Maillet J, Pasquet A, Le Tourneau T . Aortic valve replacement for low-flow/low-gradient aortic stenosis operative risk stratification and long-term outcome: a European multicenter study. J Am Coll Cardiol. 2008; 51(15):1466-72. DOI: 10.1016/j.jacc.2007.10.067. View

11.

Clavel M, Messika-Zeitoun D, Pibarot P, Aggarwal S, Malouf J, Araoz P . The complex nature of discordant severe calcified aortic valve disease grading: new insights from combined Doppler echocardiographic and computed tomographic study. J Am Coll Cardiol. 2013; 62(24):2329-38. DOI: 10.1016/j.jacc.2013.08.1621. View