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"Pure" severe aortic stenosis without concomitant valvular heart diseases: echocardiographic and pathophysiological
J Kandels1, B Tayal2, A Hagendorff3
1Department of Cardiology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany. joscha.kandels@medizin.uni-leipzig.de.
Insights
The study found that combined left ventricular hypertrophy, diastolic dysfunction, and pulmonary artery hypertension are not consistently present in patients with "pure" severe aortic stenosis (AS). These findings suggest current diagnostic algorithms may overestimate AS severity.
Area of Science:
- Cardiology
- Echocardiography
- Cardiac Physiology
Background:
- Aortic stenosis (AS) severity is typically assessed using echocardiography metrics like effective orifice area (EOA), mean pressure gradient (mPG_AV), and transvalvular flow velocity (maxV_AV).
- The presence of secondary cardiac alterations such as left ventricular hypertrophy (LVH), diastolic dysfunction (DD), and pulmonary artery hypertension (PAH) is often considered a hallmark of severe AS.
Purpose of the Study:
- To investigate the pathophysiological presence of combined LVH, DD, and PAH in patients diagnosed with
- pure
- severe AS.
- To evaluate the diagnostic accuracy of current echocardiographic parameters in assessing AS severity.
Main Methods:
- Retrospective analysis of 306 patients with "pure" severe AS (indexed EOA < 0.6 cm2).
- Patients were categorized into four subgroups based on mean pressure gradient (mPG_AV) and left ventricular stroke volume (low flow/low gradient, normal flow/low gradient, low flow/high gradient, normal flow/high gradient).
- Echocardiographic parameters including LVH, DD, and PAH were assessed.
Main Results:
- Only 43% of patients met the criteria for high gradient AS (mPG_AV > 40 mmHg and maxV_AV > 4 m/s), indicating incongruencies in severity assessment.
- LVH was present in 81%, DD in 76%, and PAH in 80% of patients.
- 54% of patients exhibited all three secondary alterations; however, their presence was not consistently confirmed across all "pure" severe AS classifications.
Conclusions:
- The study could not confirm the consistent presence of combined LVH, DD, and PAH as accepted sequelae in all patients with "pure" severe AS.
- The findings suggest that the detection of these secondary cardiac alterations may need refinement to avoid overestimation of AS severity.
- Current echocardiographic parameters for AS severity assessment may require re-evaluation.
Purpose:
In echocardiography the severity of aortic stenosis (AS) is defined by effective orifice area (EOA), mean pressure gradient (mPGAV) and transvalvular flow velocity (maxVAV). The hypothesis of the present study was to confirm the pathophysiological presence of combined left ventricular hypertrophy (LVH), diastolic dysfunction (DD) and pulmonary artery hypertension (PAH) in patients with "pure" severe AS.
Methods And Results:
Patients (n = 306) with asymptomatic (n = 133) and symptomatic (n = 173) "pure" severe AS (mean age 78 ± 9.5 years) defined by indexed EOA < 0.6 cm2 were enrolled between 2014 and 2016. AS patients were divided into 4 subgroups according to mPGAV and indexed left ventricular stroke volume: low flow (LF) low gradient (LG)-AS (n = 133), normal flow (NF) LG-AS (n = 91), LF high gradient (HG)-AS (n = 21) and NFHG-AS (n = 61). Patients with "pure" severe AS showed mean mPGAV of 31.7 ± 9.1 mmHg and mean maxVAV of 3.8 ± 0.6 m/s. Only 131 of 306 patients (43%) exhibited mPGAV > 40 mmHg and maxVAV > 4 m/s documenting incongruencies of the AS severity assessment by Doppler echocardiography. LVH was documented in 81%, DD in 76% and PAH in 80% of AS patients. 54% of "pure" AS patients exhibited all three alterations. Ranges of mPGAV and maxVAV were higher in patients with all three alterations compared to patients with less than three. 224 (73%) patients presented LG-conditions and 82 (27%) HG-conditions. LVH was predominant in NF-AS (p = 0.014) and PAH in LFHG-AS (p = 0.014). Patients' treatment was retrospectively assessed (surgery: n = 100, TAVI: n = 48, optimal medical treatment: n = 156).
Conclusion:
In patients with "pure" AS according to current guidelines the presence of combined LVH, DD and PAH as accepted pathophysiological sequelae of severe AS cannot be confirmed. Probably, the detection of these secondary cardiac alterations might improve the diagnostic algorithm to avoid overestimation of AS severity.
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