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A Better Way to Predict Outcome in Low-Flow Aortic Stenosis

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Authors: Annabi MS et al. 

J Am Coll Cardiol 2018 Feb 6.

Calculating the projected aortic valve area may be better than the usual dobutamine stress echocardiographic criteria for identifying severe AS.

Distinguishing between true severe aortic stenosis (AS) and pseudo-severe AS in patients with low gradient, low left ventricular ejection fraction (LVEF), and calculated low aortic valve area (AVA) is difficult. Current guidelines suggest assessment with dobutamine stress echocardiography (DSE). These investigators compared DSE using the usual criteria for severe AS (at peak dobutamine dose: mean gradient, ≥40 mm Hg; AVA ≤1 cm2) with DSE measuring the projected AVA at normal transvalvular flow (250 mL/minute) in 186 patients (mean gradient, <40 mm Hg; indexed AVA, ≤0.6 cm2/m2; LVEF, ≤40).

Severity of AS was assessed in 87 patients by computed tomography calcium score or by direct examination during surgery. In this subgroup, the sensitivity for identification of true severe AS was better with projected AVA (86%) than with the usual DSE criteria (63%), resulting in a higher percentage of correctly classified patients (70% vs. 60%).

In 88 medically managed patients, a low projected AVA predicted mortality at 4 years (hazard ratio, 3.78), whereas the usual DSE criteria had wider confidence intervals and a statistically nonsignificant hazard ratio.

COMMENT

This study of classical low-flow, low-gradient, low-EF AS patients suggests that the usual criteria measured during DSE have a low sensitivity for identifying severe AS and do not predict mortality of medically managed patients. In contrast, the projected AVA at normal flow during DSE better classified patients into severe versus pseudo-severe AS and predicted mortality. The discordance may reflect the variable change in flow with dobutamine in individual patients, particularly the persistence of a low-flow state in some patients. As the editorialist suggests, evaluation of these patients is complicated, requires an integrated approach, and, based on this study, should also include calculation of the projected AVA.

CITATION(S):

Annabi MS et al. Dobutamine stress echocardiography for management of low-flow, low-gradient aortic stenosis. J Am Coll Cardiol 2018 Feb 6; 71:475. (https://doi.org/10.1016/j.jacc.2017.11.052)

Grayburn PA. Evaluating patients with low-flow, low-gradient aortic stenosis by dobutamine echocardiography: It’s complicated. J Am Coll Cardiol 2018 Feb 6; 71:486. (https://doi.org/10.1016/j.jacc.2017.12.017)

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