[Calcified aortic stenosis with left ventricular dysfunction and low transvalvular gradients. Must one reject surgery
1Fédération de cardiologie, CHU Henri Mondor, AP-HP, 51, avenue de Lattre de Tassigny, 94 010 Créteil. jeanluc.monin@free.fr
Insights
Dobutamine echocardiography helps manage severe aortic stenosis by identifying patients who benefit from surgery versus medical therapy. It assesses left ventricular contractile reserve to predict operative risk and guide treatment decisions.
Area of Science:
- Cardiology
- Echocardiography
- Valvular Heart Disease
Background:
- Severe aortic stenosis with left ventricular dysfunction and low gradients presents a high operative risk.
- Accurate assessment is crucial for appropriate management of this complex condition.
Purpose of the Study:
- To evaluate the role of dobutamine echocardiography in assessing severe aortic stenosis.
- To differentiate between true and relative aortic stenosis.
- To predict operative risk and guide treatment strategies.
Main Methods:
- Utilized dobutamine echocardiography to assess aortic valve area and left ventricular contractile reserve.
- Analyzed patient outcomes based on dobutamine stress test results.
- Correlated findings with operative risk and treatment efficacy.
Main Results:
- Dobutamine echocardiography accurately identifies relative aortic stenosis due to low cardiac output, suggesting medical management.
- Left ventricular contractile reserve (≥20% stroke volume increase) indicates lower operative risk (5-10%) and benefits from valve replacement.
- Absence of contractile reserve signifies higher operative risk (30-60%), influenced by gradient, need for bypass, and comorbidities, but is not an absolute contraindication.
Conclusions:
- Dobutamine echocardiography is a valuable tool for risk stratification in severe aortic stenosis with systolic dysfunction.
- It aids in selecting patients for surgical intervention versus conservative medical management.
- Assessment of contractile reserve is key to predicting surgical outcomes and guiding therapeutic decisions.
Abstract:
The natural history of severe aortic stenosis (aortic valve area < 1 cm2 or < 0.6 cm2/m2) with left ventricular systolic dysfunction and low transvalvular gradients (mean gradient < 40 mmHg) is mediocre in the short term and the operative risk is high. Dobutamine echocardiography provides a reliable evaluation of the aortic obstacle by diagnosing the rare cases of relative aortic stenosis in which the valve surface area has been underestimated because of a low cardiac output (aortic surface area > 1.2 cm2 with a mean gradient < 30 mmHg with dobutamine): in this case, the limited available data suggests that medical therapy with strict follow-up of its efficacy is the best management. The other use of dobutamine echocardiography is to assess left ventricular contractile reserve, defined as a increase > or = 20% in stroke volume under dobutamine. Cases with a contractile reserve have an operative risk of 5 to 10% and the medium-term benefits of valve replacement have been demonstrated. In the absence of contractile reserve, the operative risk is much grater, 30 to 60%, and also depends on other parameters such as the mean basal transaortic pressure gradient (risk five times greater in cases with a mean gradient < 20 mmHg), the need for coronary bypass surgery and associated co-morbid conditions. The surgical contraindications are in fact relatively few and concern patients with several risk factors: absence of contractile reserve itself is not a definitive surgical contraindication.
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