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Elkaryoni A, Huded CP, Saad M, Altibi AM, Chhatriwalla AK, Abbott JD, Arnold SV. Normal-Flow Low-Gradient Aortic Stenosis: Comparing the U.S. and European Guidelines. JACC Cardiovasc Imaging 2024:S1936-878X(24)00118-9. [PMID: 38703172 DOI: 10.1016/j.jcmg.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 05/06/2024]
Abstract
Patients with normal-flow low-gradient (NFLG) severe aortic stenosis present both diagnostic and management challenges, with debate about the whether this represents true severe stenosis and the need for valve replacement. Studies exploring the natural history without intervention have shown similar outcomes of patients with NFLG severe aortic stenosis to those with moderate aortic stenosis and better outcomes after valve replacement than those with low-flow low-gradient severe aortic stenosis. Most studies (all observational) have shown that aortic valve replacement was associated with a survival benefit vs surveillance. Based on available data, the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines and European Association of Cardiovascular Imaging/American Society of Echocardiography suggest that these patients are more likely to have moderate aortic stenosis. This clinical entity is not mentioned in the American Heart Association/American College of Cardiology guidelines. Here we review the definition of NFLG severe aortic stenosis, potential diagnostic algorithms and points of error, the data supporting different management strategies, and the differing guidelines and outline the unanswered questions in the diagnosis and management of these challenging patients.
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA.
| | - Chetan P Huded
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Marwan Saad
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Ahmed M Altibi
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Adnan K Chhatriwalla
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - J Dawn Abbott
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Aguilar-Molina O, Barbosa-Balaguera S, Campo-Rivera N, Cabrales-Salcedo Y, Camacho-Garcia R, Herrera-Escandón Á. Low-Flow, Low-Gradient Severe Aortic Stenosis in patients with preserved or reduced ejection fraction: a systematic literature review. Curr Probl Cardiol 2024; 49:102392. [PMID: 38232925 DOI: 10.1016/j.cpcardiol.2024.102392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/14/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVES A systematic review of the literature was conducted to analyze the current evidence on low-flow, low-gradient severe aortic stenosis. This analysis aimed to differentiate between subgroups of patients with reduced and preserved left ventricular ejection fraction (LVEF). METHODS After conducting a systematic literature review, 35 observational studies were included. Out of these, 28 were prospective and 7 retrospective. The studies that included a mortality risk stratification of low-flow, low-gradient aortic stenosis (LF- LG AS) with both preserved and reduced LVEF were reviewed. RESULTS The importance of considering multiple clinical and echocardiographic variables in diagnostic evaluation and therapeutic decision-making was highlighted. CONCLUSIONS LF- LG AS, in any of its subgroups, is a common and challenging valve lesion. A careful assessment of severity and, in specific scenarios, a thorough reclassification is important. More high-quality studies are required to more precisely define the classification and prognosis of this entity.
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Affiliation(s)
- Oswaldo Aguilar-Molina
- Cardiology Unit, Universidad del Valle, Cali, Colombia; Hospital Universitario del Valle, Cali, Colombia
| | - Stephany Barbosa-Balaguera
- Cardiology Unit, Universidad del Valle, Cali, Colombia; Hospital Universitario del Valle, Cali, Colombia
| | - Natalia Campo-Rivera
- Cardiology Unit, Universidad del Valle, Cali, Colombia; Hospital Universitario del Valle, Cali, Colombia
| | | | | | - Álvaro Herrera-Escandón
- Cardiology Unit, Universidad del Valle, Cali, Colombia; Hospital Universitario del Valle, Cali, Colombia
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Yuan Y, Herrington D, Lima JA, Stacey RB, Zhao D, Thomas J, Garcia M, Pu M. Assessment of Prevalence, Clinical Characteristics, and Risk Factors Associated With "Low Flow State" Using Cardiac Magnetic Resonance. Mayo Clin Proc Innov Qual Outcomes 2023; 7:443-451. [PMID: 37818141 PMCID: PMC10562103 DOI: 10.1016/j.mayocpiqo.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Objective To assess prevalence, clinical characteristics, and risk factors associated with low flow state (LFS) in a multiethnic population with normal left ventricular ejection fraction (LVEF). Patients and Methods The study included 4398 asymptomatic participants undergoing cardiac magnetic resonance from July 17, 2000, to August 29, 2002. Left ventricular (LV) mass, volume, and myocardial contraction fraction were assessed. Low flow state was defined as stroke volume index (SVi of <35 mL/m2). Clinical characteristics, cardiac risk factors, and cardiac magnetic resonance findings were compared between LFS and normal flow state (NFS) groups (NFS: SVi of ≥35 mL/m2). Results There were significant differences in the prevalence of LFS in different ethnic groups. Individuals with LFS were older (66±9.6 vs 61±10 years; P<.0001). The prevalence of LFS was 19% in the group aged older than 70 years. The logistic multivariable regression analysis found that age was independently associated with LFS. The LFS group had significantly higher prevalence of diabetes (30% vs 24%; P=.001), LV mass-volume ratio (1.13±0.22 vs 0.91±0.15; P<.0001), inflammatory markers, a lower LV mass index (59±10 vs 65±11 kg/m2; P<.001), lower myocardial contraction fraction (58.1±10.6% vs 75.7±13%; P<.001), and a lower left atrial size index (32.2±4.6 vs 36.7±5.9 mm/m2; P<.0001) than NFS. Conclusion Low flow state may be considered an under-recognized clinical entity associated with increasing age, multiple risk factors, increased inflammatory markers, a lower LV mass index, and suboptimal myocardial performance despite the presence of normal LVEF and absence of valvular disease.
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Affiliation(s)
- Yifang Yuan
- Section on Cardiology, Wake Forest University Cardiology, Johns Hopkins University, Winston-Salem, NC
| | - David Herrington
- Section on Cardiology, Wake Forest University Cardiology, Johns Hopkins University, Winston-Salem, NC
| | - Joao A.C. Lima
- Division of Cardiology, Johns Hopkins University, Baltimore, ML
| | - R. Brandon Stacey
- Section on Cardiology, Wake Forest University Cardiology, Johns Hopkins University, Winston-Salem, NC
| | - David Zhao
- Section on Cardiology, Wake Forest University Cardiology, Johns Hopkins University, Winston-Salem, NC
| | - James Thomas
- Division of Cardiology, Northwestern University, School of Medicine, Chicago, IL
| | - Mario Garcia
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Min Pu
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Kozak PM, Pu M, Swett K, Daviglus ML, Kansal MM, Sotres-Alvarez D, Ponce SG, Kaplan R, Garcia M, Rodriguez CJ. Echocardiographic Investigation of Low-Flow State in a Hispanic/Latino Population. Mayo Clin Proc Innov Qual Outcomes 2022; 6:388-397. [PMID: 35938139 PMCID: PMC9352799 DOI: 10.1016/j.mayocpiqo.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the prevalence of low-flow state (LFS) with left ventricular (LV) stroke volume index of less than 35 mL/m2 and the demographics, clinical and echocardiographic characteristics associated with LV remodeling and function in a Hispanic/Latino population. Participants and Methods The study included 1346 asymptomatic participants from the Hispanic Community Health Study/Study of Latinos with normal LV ejection fraction (≥55%) and no valvular heart disease. LV volume, mass and left atrial volume, LV ejection fraction, global longitudinal strain, and myocardial contraction fraction were measured by echocardiography. The participants were divided into LFS or normal flow state (NFS: stroke volume index ≥35 mL/m2). Demographics, clinical and echocardiographic characteristics, and measures of LV remodeling and function were compared between the LFS and NFS groups. Results The prevalence of LFS was 41%. In comparison with NFS, the LFS had lower LV mass index (77.2±0.96 g/m2 vs 84.6±0.86 g/m2; P<.001), left atrial volume index (20.6±0.35 mL/m2 vs 23.5±0.37 mL/m2; P<.001), global longitudinal strain (−16.8±0.16% vs −17.7±0.17%; P<.001), and myocardial contraction fraction (43.3±0.63% vs 55.7±0.64%; P<.001). There was no significant difference in the relative wall thickness (LFS: 0.40±0.004 vs NFS: 0.40±0.005; P=.57). The LFS group had significantly higher hemoglobin A1c (6.18±0.07% vs 5.97±0.04%; P=.01) than the NFS group. Conclusion A high prevalence of LFS associated with echocardiographic characteristics reflecting unfavorable LV remodeling and function was observed in a Hispanic/Latino population. Further studies of the prognostic significance of LFS in a large multiethnic population are warranted.
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Alkurashi AK, Pislaru SV, Thaden JJ, Collins JD, Foley TA, Greason KL, Eleid MF, Sandhu GS, Alkhouli MA, Asirvatham SJ, Cha YM, Williamson EE, Crestanello JA, Pellikka PA, Oh JK, Nkomo VT. Doppler Mean Gradient Is Discordant to Aortic Valve Calcium Scores in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2021; 35:116-123. [PMID: 34506919 DOI: 10.1016/j.echo.2021.08.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography. RESULTS Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76-86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm2/m2 [IQR, 0.39-0.47 cm2/m2] vs 0.46 cm2/m2 [IQR, 0.41-0.51 cm2/m2], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803-4,030 AU] vs 2,722 AU [IQR, 2,180-3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS. CONCLUSIONS AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.
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Affiliation(s)
- Adham K Alkurashi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Thomas A Foley
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gurpreet S Sandhu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Fan Y, Shen H, Stacey B, Zhao D, Applegate RJ, Kon ND, Kincaid EH, Gandhi SK, Pu M. Echocardiography and EuroSCORE II for the stratification of low-gradient severe aortic stenosis and preserved left ventricular ejection fraction. Int J Cardiovasc Imaging 2021; 37:3169-3176. [PMID: 34392468 PMCID: PMC8557199 DOI: 10.1007/s10554-021-02373-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/03/2021] [Indexed: 11/02/2022]
Abstract
The purpose of this study was to explore the utility of echocardiography and the EuroSCORE II in stratifying patients with low-gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF ≥ 50%) with or without aortic valve intervention (AVI). The study included 323 patients with LG SAS (aortic valve area ≤ 1.0 cm2 and mean pressure gradient < 40 mmHg). Patients were divided into two groups: a high-risk group (EuroSCORE II ≥ 4%, n = 115) and a low-risk group (EuroSCORE II < 4%, n = 208). Echocardiographic and clinical characteristics were analyzed. All-cause mortality was used as a clinical outcome during mean follow-up of 2 ± 1.3 years. Two-year cumulative survival was significantly lower in the high-risk group than the low-risk patients (62.3% vs. 81.7%, p = 0.001). AVI tended to reduce mortality in the high-risk patients (70% vs. 59%; p = 0.065). It did not significantly reduce mortality in the low-risk patients (82.8% with AVI vs. 81.2%, p = 0.68). Multivariable analysis identified heart failure, renal dysfunction and stroke volume index (SVi) as independent predictors for mortality. The study suggested that individualization of AVI based on risk stratification could be considered in a patient with LG SAS and preserved LVEF.
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Affiliation(s)
- Yan Fan
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,First Hospital, Peking University, Beijing, China
| | - Hong Shen
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Brandon Stacey
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - David Zhao
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Robert J Applegate
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Neal D Kon
- Section of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Edward H Kincaid
- Section of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Sanjay K Gandhi
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Min Pu
- Section on Cardiovascular Medicine, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
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Impact of Surgical and Transcatheter Aortic Valve Replacement in Low-Gradient Aortic Stenosis: A Meta-Analysis. JACC Cardiovasc Interv 2021; 14:1481-1492. [PMID: 33939605 DOI: 10.1016/j.jcin.2021.04.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this study was to assess the impact of aortic valve replacement (AVR) on survival in patients with each subclass of low-gradient (LG) aortic stenosis (AS) and to compare outcomes following surgical AVR (SAVR) and transcatheter AVR (TAVR). BACKGROUND LG severe AS encompasses a wide variety of pathophysiology, including classical low-flow, LG (LF-LG), paradoxical LF-LG, and normal-flow, LG (NF-LG) AS, and uncertainty exists regarding the impact of AVR on each subclass of LG AS. METHODS PubMed and Embase were queried through October 2020 to identify studies comparing survival with different management strategies (SAVR, TAVR, and conservative) in patients with LG AS. Pairwise meta-analysis comparing AVR versus conservative management and network meta-analysis comparing SAVR versus TAVR versus conservative management were performed. RESULTS Thirty-two studies with a total of 6,515 patients and a median follow-up time of 24.2 months (interquartile range: 36.5 months) were included. AVR was associated with a significant decrease in all-cause mortality in classical LF-LG (hazard ratio [HR]: 0.42; 95% confidence interval [CI]: 0.36 to 0.48), paradoxical LF-LG (HR: 0.41; 95% CI: 0.29 to 0.57), and NF-LG (HR: 0.41; 95% CI: 0.27 to 0.62) AS compared with conservative management. SAVR and TAVR were each associated with a decrease in all-cause mortality in classical LF-LG (HR: 0.46 [95% CI: 0.38 to 0.55] and 0.49 [95% CI: 0.37 to 0.64], respectively), paradoxical LF-LG (HR: 0.42 [95% CI: 0.28 to 0.65] and 0.42 [95% CI: 0.25 to 0.72], respectively), and NF-LG (HR: 0.40 [95% CI: 0.21 to 0.77] and 0.46 [95% CI: 0.26 to 0.84], respectively) AS compared with conservative management. No significant difference was observed between SAVR and TAVR. CONCLUSIONS In all subclasses of LG AS, AVR was associated with a significant decrease in all-cause mortality regardless of surgical or transcatheter approach.
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Pu M. Regarding "Estimation of Stroke Volume and Aortic Valve Area in Patients with Aortic Stenosis: A Comparison of Echocardiography versus Cardiovascular Magnetic Resonance". J Am Soc Echocardiogr 2020; 34:104-106. [PMID: 32919858 DOI: 10.1016/j.echo.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/04/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Min Pu
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Pu M, Dong Z, Zhou L, Stacey RB, Richardson K, Applegate RJ, Zhao D. Impact of anatomical variations of the left ventricular outflow tract on stroke volume calculation by Doppler echocardiography in aortic stenosis. Echocardiography 2020; 37:815-821. [PMID: 32427382 DOI: 10.1111/echo.14681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Accurate calculation of stroke volume (SV) by Doppler echocardiography is important for the assessment of aortic stenosis (AS), which may be impacted by anatomical variations of left ventricular outflow tract (LVOT). METHODS Patients with AS (n = 64) were studied using computed tomography (CT) and transthoracic echocardiography (TTE). Anatomical variations of LVOT areas were measured at (a) the aortic annulus (Aa ); (b) 5 mm (A5 ); and (c) 10 mm below the annulus (A10 ) by CT. LVOT diameters were also measured by 2D TTE at these three levels for calculation of LVOT areas. Stroke volumes (SV) were calculated using continuity equation. The impacts of anatomical variations of LVOT on SV calculation were evaluated. RESULTS Anatomical LVOT area increased from Aa to A10 (5.0 ± 0.9 cm2 vs 5.8 ± 1.9 cm2 , P < .01). Differences between TTE-calculated LVOT areas and anatomical areas were most significant at A10 due to elongation of mediolateral diameters with variable changes in anteroposterior diameters (5.8 ± 1.9 cm2 vs 3.4 ± 1.1 cm2 , P < .001). Although mean calculated SV by TTE was not significant at different LVOT levels (Aa 69 ± 22 mL, vs A5 66 ± 21 mL, vs A10 66 ± 28 ± 22 mL, P > .05), the most significant variations in individuals were at A10 levels (ΔSV: 8.2 ± 6.4 mL, 12 ± 9%). CONCLUSION Variations of LVOT anatomy in individuals with AS significantly impact the SV calculated by Doppler echocardiography. These features should be taken into account for AS diagnosis and a clinical decision-making for intervention.
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Affiliation(s)
- Min Pu
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Zhifeng Dong
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Li Zhou
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Richard B Stacey
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Karl Richardson
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Robert J Applegate
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - David Zhao
- Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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