Prospective assessment of the frequency of low gradient severe aortic stenosis with preserved left ventricular ejection fraction: Critical impact of aortic flow misalignment and pressure recovery phenomenon

Anne Ringle (1, 2, 3) , Anne-Laure Castel (2, 1) , Caroline Le Goffic (2, 1) , Francois Delelis (2, 1) , Camille Binda (2, 1) , Yohann Bohbot (4) , Pierre Vladimir Ennezat (5) , Raphaëlle-Ashley Guerbaai (5) , Franck Levy (6) , André Vincentelli (7) , Pierre Graux (2, 1) , Christophe Tribouilloy (4, 3) , Sylvestre Marechaux (2, 1, 3)

1 GHICL - Groupement des Hôpitaux de l'Institut Catholique de Lille
2 UCL - Université catholique de Lille
3 MP3CV - Mécanismes physiopathologiques et conséquences des calcifications vasculaires - UR UPJV 7517
4 CHU Amiens-Picardie
5 CHU - Centre Hospitalier Universitaire [Grenoble]
6 CCTM - Centre Cardio-Thoracique de Monaco
7 CHRU Lille - Centre Hospitalier Régional Universitaire [Lille]

Background. - The frequency of paradoxical low-gradient severe aortic stenosis (AS) varies widely across studies. The impact of misalignment of aortic flow and pressure recovery phenomenon on the frequency of low-gradient severe AS with preserved left ventricular ejection fraction (LVEF) has not been evaluated in prospective studies. Aims. - To investigate prospectively the impact of aortic flow misalignment by Doppler and lack of pressure recovery phenomenon correction on the frequency of low-gradient (LG) severe aortic stenosis (AS) with preserved LVEF. Methods. - Aortic jet velocities and mean pressure gradient (MPG) were obtained by interrogating all windows in 68 consecutive patients with normal LVEF and severe AS (aortic valve area [AVA] <= 1 cm(2)) on the basis of the apical imaging window alone (two-dimensional [2D] apical approach). Patients were classified as having LG or high-gradient (HG) AS according to MPG < 40 mmHg or >= 40 mmHg, and normal flow (NF) or low flow (LF) according to stroke volume index > 35 mL/m(2) or <= 35 mL/m(2), on the basis of the 2D apical approach, the multiview approach (multiple windows evaluation) and AVA corrected for pressure recovery. Results. - The proportion of LG severe AS was 57% using the 2D apical approach alone. After the multiview approach and correction for pressure recovery, the proportion of LG severe AS decreased from 57% to 13% (LF-LG severe AS decreased from 23% to 3%; NF-LG severe AS decreased from 34% to 10%). As a result, 25% of patients were reclassified as having HG severe AS (AVA <= 1 cm(2) and MPG >= 40 mmHg) and 19% as having moderate AS. Hence, 77% of patients initially diagnosed with LG severe AS did not have ``true'' LG severe AS when the multiview approach and the pressure recovery phenomenon correction were used. Conclusions. - Aortic flow misevaluation, resulting from lack of use of multiple windows evaluation and pressure recovery phenomenon correction, accounts for a large proportion of incorrectly graded AS and considerable overestimation of the frequency of LG severe AS with preserved LVEF. (C) 2018 Elsevier Masson SAS. All rights reserved.

Mots clés: Aortic stenosis; Bas gradient; Doppler echocardiography; Low gradient; Pressure recovery; Restitution de pression; Rétrécissement aortique; Échocardiographie Doppler

Domaines: Sciences du Vivant [q-bio]

Anne Ringle, Anne-Laure Castel, Caroline Le Goffic, Francois Delelis, Camille Binda, et al.. Prospective assessment of the frequency of low gradient severe aortic stenosis with preserved left ventricular ejection fraction: Critical impact of aortic flow misalignment and pressure recovery phenomenon. Archives of cardiovascular diseases, 2018, 111 (8-9), pp.518-527. ⟨10.1016/j.acvd.2017.11.004⟩. ⟨hal-03580334⟩