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Health Dictionary

Reliable, easy-to-read patient information on common medical conditions — written in plain language, free of jargon, and grounded in current evidence. Browse the most frequent diagnoses, understand what they mean for everyday life, and learn which steps and questions help you have a focused conversation with your doctor.

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Low flow low gradient aortic stenosis resident survival guide

Introduction

Overview

Overview

When severe systolic and/or diastolic myocardial dysfunction coexist with aortic stenosis, there is a decrease in the flow through the valve leading to a prominent decrease in the transvalvular gradient, a condition referred to as low flow low gradient aortic stenosis (LF-LG AS). LF-LG AS with is defined as:

  1. An aortic valve areas < 1.0 cm2, and
  2. A mean pressure difference or gradient across the aortic valve of < 40 mm Hg
Management

Management

Shown below is an algorithm of the management of low flow, low gradient aortic stenosis.[1]

Abbreviations: AVR: Aortic valve replacement; EOA: Effective orifice area; ΔPmean: mean pressure gradient

 
 
Ultrasound evaluation of aortic stenosis
Effective orifice area (EOA)≤ 1 cm2
Pressure gradient (ΔP)<40 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low grade low flow aortic stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal left ventricular ejection fraction
 
Left ventricular ejection fraction≤ 40-50%[2]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No specific recommendations:
– Surgical AVR, or
– Transcather AVR, or
– Medical treatment
 
 
 
 
 
 
 
 
 
 
 
Dobutamine stress test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increase in stroke volume by ≥ 20%
 
Increase in stroke volume by <20%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of left ventricular flow reserve
 
Absence of left ventricular flow reserve
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ΔP≥40
EOA<1-1.2
 
ΔP<40
EOA≥1-1.2
 
EOA<1-1.2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
True severe aortic stenosis
 
Pseudo-severe aortic stenosis
 
True severe aortic stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical AVR
with/without CABG
 
Medical treatment
Close follow up
 
Transcather AVR
References

References

  1. ↑ Pibarot P, Dumesnil JG (2012). “Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction”. J Am Coll Cardiol. 60 (19): 1845–53. doi:10.1016/j.jacc.2012.06.051. PMID 23062546.
  2. ↑ Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O’Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). “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. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]