Surgery for Severe Aortic stenosis with Low Transvalvular Gradient and Poor LV Function

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SURGERY FOR SEVERE AORTIC STENOSIS WITH LOW
TRANSVALVULAGRADIENT AND POOR LV FUNCTION
Surgery for Severe Aortic stenosis with Low Transvalvular
Gradient and Poor LV Function

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Introduction
 The results of aortic valve replacement are uncertain among patients with severe
aortic stenosis, reduced LV ejection fraction (LVEF), and low transvalvular mean
gradient.
 Although these patients represent ,5% of patients with aortic stenosis, they also
represent the most controversial subset.
 Increased perioperative risk and reduced late outcome compared with controls have
been reported in patients with reduced LVEF
 Few data are available on the clinical outcome of patients with aortic stenosis,
decreased LVEF, and low transvalvular mean gradient who undergo aortic
valve replacement. Therefore, we tested the hypothesis that aortic valve
replacement in patients
2 Introduction

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OBSERVATION
 Perioperative (30-day) mortality was 3.1 % (1 of 32
patients). The mean aortic prosthesis size was 23±1.8
mm .Postoperative functional improvement occurred in
most patients. 75% (n=24)were severely symptomatic
(NYHA class III or IV) before and only 18.6%(n=6) were
severely symptomatic after operation.
 At 6 months follow-up ,interventricular septal wall
thickness regressed from 14±2 to 12±1 mm and
posterior wall thickness from 13±3 to
11±2mm.Postoperative EF was assessed in survivors;
80.6% (n=26) showed a positive change. The mean
change was an increase of 10±12 EF units .Positive
change in EF was related to smaller preoperative aortic
valve area .
 In patients with small size annulus choice of
Mechanical valve prosthesis ( 18/32) with larger
effective orifice area compared to same size
bioprosthetic valve prevented severe Patient
prosthesis mismatch

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Take Home Message
 LF-LG AS poses some important challenges with regard to confirmation of stenosis
severity and therapeutic management.
 A low dose DSE is generally used to differentiate true- versus pseudo- severe AS and
support the indication of AVR in patients with classical LF-LG who have significant flow
reserve.
 Aortic valve calcium quantification by MDCT may be helpful to distinguish true- from
pseudo- severe stenosis in patients with classical LF-LG AS in whom there is no or
minimal increase in flow during DSE and/or in whom the results of DSE are
inconclusive.
 The presence of a relatively high mean gradient, >20 mm Hg, combined with a
positive inotropic response suggest a relatively good prognosis, whereas the presence
of postoperative patient-prosthetic mismatch indicates a poorer prognosis
Take Home Message

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ConclusionConclusion

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Thank You