Dobutamine Stress Echocardiography in Patients With Low-Gradient Aortic Stenosis
2006; Lippincott Williams & Wilkins; Volume: 113; Issue: 14 Linguagem: Inglês
10.1161/circulationaha.105.617159
ISSN1524-4539
AutoresRichard A. Lange, L. David Hillis,
Tópico(s)Cardiovascular Function and Risk Factors
ResumoHomeCirculationVol. 113, No. 14Dobutamine Stress Echocardiography in Patients With Low-Gradient Aortic Stenosis Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBDobutamine Stress Echocardiography in Patients With Low-Gradient Aortic Stenosis Richard A. Lange and L. David Hillis Richard A. LangeRichard A. Lange From the Departments of Internal Medicine (Cardiology Divisions), Johns Hopkins Medical Institution, Baltimore, Md (R.A.L.), and the University of Texas Southwestern Medical Center, Dallas (L.D.H.). and L. David HillisL. David Hillis From the Departments of Internal Medicine (Cardiology Divisions), Johns Hopkins Medical Institution, Baltimore, Md (R.A.L.), and the University of Texas Southwestern Medical Center, Dallas (L.D.H.). Originally published11 Apr 2006https://doi.org/10.1161/CIRCULATIONAHA.105.617159Circulation. 2006;113:1718–1720In adults with moderate or severe aortic stenosis (AS), valve replacement surgery is recommended when symptoms (ie, angina, syncope, or congestive heart failure) appear.1 In such patients, valve replacement surgery alleviates symptoms and improves survival, even in those with a depressed left ventricular ejection fraction (LVEF). Although a minority of patients with symptomatic AS have a reduced LVEF, these individuals present challenges in evaluation and management.Article p 1738In the patient with AS and a depressed LVEF, the latter may be caused by inadequate compensatory LV hypertrophy (so-called afterload mismatch) in which myocyte function is normal but LVEF is low because of inadequate LV mass. In such an individual, symptomatic status and LVEF improve with valve replacement surgery because the operation eliminates the preexisting excessive LV afterload, thereby restoring the match between LV myocyte mass and afterload. Alternatively, a depressed LVEF may be caused by a superimposed and separate myocardial disease process such as cardiomyopathy, ischemia, or fibrosis in which myocyte function is abnormal. In these individuals, operative risk is increased, symptomatic status often does not improve, and LVEF remains depressed after valve replacement surgery.Low-Gradient ASSeveral previously published studies in subjects with AS and depressed LVEF have attempted to identify variables that may help to differentiate patients with afterload mismatch from those whose depressed LVEF is due to a separate disease process. Carabello and colleagues2 found that individuals with severe AS, depressed LVEF, and a transvalvular pressure gradient >30 mm Hg were likely to survive valve replacement surgery and to manifest symptomatic improvement postoperatively. In contrast, those with severe AS, depressed LVEF, and a low (<30 mm Hg) transvalvular pressure gradient did not benefit from valve replacement surgery; of 4 such subjects, 3 died perioperatively, and the 1 survivor did not manifest symptomatic improvement. From the outcome of these 4 patients—all of whom underwent valve replacement surgery in the 1970s, when intraoperative cardioprotection was relatively primitive—it seemed imprudent to perform valve replacement surgery in individuals with severe AS and a low transvalvular pressure gradient.In 1993, Brogan et al3 reported on 18 patients with severe AS and a low ( 0.6 m/s), stroke volume (>20%), or mean transvalvular pressure gradient (>10 mm Hg) with DSE have LV contractile reserve and would benefit from valve replacement surgery. In contrast, the absence of these changes with DSE identifies patients without LV contractile reserve whose operative risk might be prohibitively high and whose symptomatic status would be unlikely to improve after surgery.In subjects with severe AS and a low transvalvular pressure gradient, does the presence or absence of LV contractile reserve help to predict operative mortality? The answer appears to be "yes." Several recent studies showed that patients with severe AS, a low transvalvular pressure gradient, and LV contractile reserve by DSE had a perioperative mortality of only 5% to 8%, whereas those without LV contractile reserve had a distinctly higher perioperative mortality (as high as 32%).7,13,14 In the study of Quere et al,15 published in this issue of Circulation, the operative mortalities for those with and without LV contractile reserve were 6% and 33%, respectively.In subjects with severe AS and a low transvalvular pressure gradient, does the presence or absence of LV contractile reserve help to predict postoperative symptomatic status, long-term prognosis, and LVEF if the patient survives valve replacement surgery? The answer appears to be "no." From a previously reported French multicenter trial,14 Quere et al15 identified 66 patients with symptomatic AS, a mean transvalvular pressure gradient ≤40 mm Hg, and an LVEF ≤40% who survived valve replacement surgery and underwent an evaluation of functional status and LVEF postoperatively. Before valve replacement surgery, 89% were New York Heart Association functional class III or IV. LV contractile reserve was present in 46 of patients (70%) and absent in 20 (30%). Compared with those with LV contractile reserve, those without reserve had a similar (1) symptomatic status postoperatively (New York Heart Association functional class I or II in 93% versus 85%, respectively), (2) survival at 2 years (92% versus 90%, respectively), (3) increase in LVEF (19% versus 17%, respectively), and (4) postoperative LVEF (47% versus 48%, respectively) after valve replacement surgery. In short, most patients with severe AS and a low transvalvular pressure gradient manifested a substantial improvement in symptomatic status and LVEF after valve replacement surgery, and these improvements occurred with similar frequency in subjects with and without LV contractile reserve.Recommendations for the Evaluation and Management of the Patient With Low-Gradient ASIn symptomatic patients with severe AS and a low transvalvular pressure gradient, DSE should be used to distinguish fixed from pseudo-AS. The patient with pseudo-AS should not have valve replacement surgery. In the patient with fixed AS and a low transvalvular pressure gradient, DSE can be used to estimate operative mortality, after which the patient should be considered for valve replacement surgery regardless of the DSE results. Although the absence of LV contractile reserve portends an increased operative mortality, the majority of these patients survive valve replacement surgery, and most of the survivors manifest an improvement in symptoms and LVEF. One thing is clear: If such individuals do not undergo valve replacement surgery, their prognosis is abysmal. Therefore, we agree with Quere and colleagues15 that the absence of LV contractile reserve should not preclude consideration of valve replacement surgery in symptomatic subjects with severe AS and a low transvalvular pressure gradient. Even for these individuals, valve replacement surgery is the treatment of choice.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to L. David Hillis, MD, Room G5.232, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390–9030. 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Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Garbi M, Chambers J, Vannan M and Lancellotti P (2015) Valve Stress Echocardiography, JACC: Cardiovascular Imaging, 10.1016/j.jcmg.2015.02.010, 8:6, (724-736), Online publication date: 1-Jun-2015. Bilolikar A and Raff G (2015) Complimentary Role of CT/MRI in the Assessment of Aortic Stenosis Aortic Stenosis, 10.1007/978-1-4471-5242-2_7, (91-116), . Pearlman A (2011) Aortic Stenosis With Low Gradient and Poor Left Ventricular Dysfunction Dynamic Echocardiography, 10.1016/B978-1-4377-2262-8.00004-9, (18-21), . 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April 11, 2006Vol 113, Issue 14 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.105.617159PMID: 16606799 Originally publishedApril 11, 2006 KeywordsechocardiographyvalvesEditorialssurgeryPDF download Advertisement SubjectsCardiovascular SurgeryEchocardiographyValvular Heart Disease
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