Korean Circulation Journal

The Korean Society of Cardiology (대한심장학회)
권호 표지
DOI QR코드

DOI QR Code

Role of Transesophageal Echocardiography in the Diagnosis of Paradoxical Low Flow, Low Gradient Severe Aortic Stenosis

  • Abudiab, Muaz M. (Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic) ;
  • Pandit, Anil (Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic) ;
  • Chaliki, Hari P. (Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic)
  • Received : 2016.03.31
  • Accepted : 2016.06.21
  • Published : 2017.01.31
⟨ Previous Next ⟩

Abstract

Background and Objectives: Prior studies indicate that up to 35% of cases of severe aortic stenosis (AS) have paradoxical low flow, low gradient despite preserved left ventricular ejection fraction (LVEF). However, error in left ventricular outflow tract (LVOT) diameter may lead to misclassification. Herein, we determined whether measurement of LVOT diameter by transesophageal echocardiography (TEE) results in reclassification of cases to non-severe AS. Subjects and Methods: Patients with severe AS with aortic valve area (AVA) <$1cm^2$ by transthoracic echocardiography (TTE) within 6 months were studied. Paradoxical low flow, low gradient was defined as mean Doppler gradient (MG) <40 mm Hg and stroke volume index (SVI) ${\leq}35mL/m^2$. Preserved LVEF was defined as ${\geq}0.50$. Results: Among 108 patients, 12 (15%) had paradoxical low flow, low gradient severe AS despite preserved LVEF based on TTE measurement. When LVOT diameter by TEE in 2D was used, only 5 (6.3%) patients had low flow, low gradient severe AS (p<0.001). Coefficients of variability for intraobserver and interobserver measurement of LVOT were <10%. However, the limits of agreement between TTE and TEE measurement of LVOT ranged from 0.43 cm (95% confidence interval [CI]: 0.36 to 0.5) to -0.31 cm (95% CI: -0.38 to -0.23). Conclusion: TEE measured LVOT diameter may result in reclassification to moderate AS in some patients due to low prevalence of true paradoxical low flow, low gradient (PLFLG) severe AS.

Keywords

References

  1. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet 2006:368:1005-11. https://doi.org/10.1016/S0140-6736(06)69208-8
  2. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009:22:1-23; quiz 101-2. https://doi.org/10.1016/j.echo.2008.11.029
  3. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014:129:e521-643.
  4. Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 2007:115:2856-64. https://doi.org/10.1161/CIRCULATIONAHA.106.668681
  5. Pibarot P, Dumesnil JG. Assessment of aortic stenosis severity: when the gradient does not fit with the valve area. Heart 2010:96:1431-3. https://doi.org/10.1136/hrt.2010.195149
  6. Zoghbi WA, Farmer KL, Soto JG, Nelson JG, Quinones MA. Accurate noninvasive quantification of stenotic aortic valve area by Doppler echocardiography. Circulation 1986:73:452-9. https://doi.org/10.1161/01.CIR.73.3.452
  7. Garcia D, Pibarot P, Dumesnil JG, Sakr F, Durand LG. Assessment of aortic valve stenosis severity: A new index based on the energy loss concept. Circulation 2000:101:765-71. https://doi.org/10.1161/01.CIR.101.7.765
  8. Hachicha Z, Dumesnil JG, Pibarot P. Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis. J Am Coll Cardiol 2009:54:1003-11. https://doi.org/10.1016/j.jacc.2009.04.079
  9. Altiok E, Koos R, Schroder J, et al. Comparison of two-dimensional and three-dimensional imaging techniques for measurement of aortic annulus diameters before transcatheter aortic valve implantation. Heart 2011:97:1578-84. https://doi.org/10.1136/hrt.2011.223974
  10. Messika-Zeitoun D, Serfaty JM, Brochet E, et al. Multimodal assessment of the aortic annulus diameter: implications for transcatheter aortic valve implantation. J Am Coll Cardiol 2010:55:186-94. https://doi.org/10.1016/j.jacc.2009.06.063
  11. Utsunomiya H, Yamamoto H, Horiguchi J, et al. Underestimation of aortic valve area in calcified aortic valve disease: effects of left ventricular outflow tract ellipticity. Int J Cardiol 2012:157:347-53. https://doi.org/10.1016/j.ijcard.2010.12.071
  12. Kempfert J, Van Linden A, Lehmkuhl L, et al. Aortic annulus sizing: echocardiographic versus computed tomography derived measurements in comparison with direct surgical sizing. Eur J Cardiothorac Surg 2012:42:627-33. https://doi.org/10.1093/ejcts/ezs064
  13. Shiran A, Adawi S, Ganaeem M, Asmer E. Accuracy and reproducibility of left ventricular outflow tract diameter measurement using transthoracic when compared with transesophageal echocardiography in systole and diastole. Eur J Echocardiogr 2009:10:319-24.
  14. Pibarot P, Garcia D, Dumesnil JG. Energy loss index in aortic stenosis: from fluid mechanics concept to clinical application. Circulation 2013:127:1101-4. https://doi.org/10.1161/CIRCULATIONAHA.113.001130
  15. Ng AC, Delgado V, van der Kley F, et al. Comparison of aortic root dimensions and geometries before and after transcatheter aortic valve implantation by 2- and 3-dimensional transesophageal echocardiography and multislice computed tomography. Circ Cardiovasc Imaging 2010:3:94-102. https://doi.org/10.1161/CIRCIMAGING.109.885152
  16. Clavel MA, Rodes-Cabau J, Dumont E, et al. Validation and characterization of transcatheter aortic valve effective orifice area measured by Doppler echocardiography. JACC Cardiovasc Imaging 2011:4:1053-62. https://doi.org/10.1016/j.jcmg.2011.06.021
  17. Pibarot P, Dumesnil JG. Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. J Am Coll Cardiol 2012:60:1845-53. https://doi.org/10.1016/j.jacc.2012.06.051
  18. Jander N, Minners J, Holme I, et al. Outcome of patients with lowgradient "severe" aortic stenosis and preserved ejection fraction. Circulation 2011:123:887-95. https://doi.org/10.1161/CIRCULATIONAHA.110.983510
  19. Tribouilloy C, Rusinaru D, Marechaux S, et al. Low-gradient, low-flow severe aortic stenosis with preserved left ventricular ejection fraction: characteristics, outcome, and implications for surgery. J Am Coll Cardiol 2015:65:55-66. https://doi.org/10.1016/j.jacc.2014.09.080
  20. Kim KS, Maxted W, Nanda NC, et al. Comparison of multiplane and biplane transesophageal echocardiography in the assessment of aortic stenosis. Am J Cardiol 1997:79:436-41. https://doi.org/10.1016/S0002-9149(96)00782-5
  21. Malyar NM, Schlosser T, Barkhausen J, et al. Assessment of aortic valve area in aortic stenosis using cardiac magnetic resonance tomography: comparison with echocardiography. Cardiology 2008:109:126-34. https://doi.org/10.1159/000105554
  22. Reant P, Lederlin M, Lafitte S, et al. Absolute assessment of aortic valve stenosis by planimetry using cardiovascular magnetic resonance imaging: comparison with transesophageal echocardiography, transthoracic echocardiography, and cardiac catheterisation. Eur J Radiol 2006:59:276-83. https://doi.org/10.1016/j.ejrad.2006.02.011
  23. Khaw AV, von Bardeleben RS, Strasser C, et al. Direct measurement of left ventricular outflow tract by transthoracic real-time 3D-echocardiography increases accuracy in assessment of aortic valve stenosis. Int J Cardiol 2009:136:64-71. https://doi.org/10.1016/j.ijcard.2008.04.070