April 21, 2026Journal of the American College of Cardiology
Low-Flow, Low-Gradient Aortic Stenosis With Normal and Depressed Left Ventricular Ejection Fraction
Key result
LF-LG AS diagnosis requires distinguishing true from pseudosevere stenosis in depressed LVEF and restrictive physiology in normal LVEF.
Why the study?
Low-flow, low-gradient aortic stenosis with depressed or preserved LVEF presents major diagnostic and therapeutic challenges, including distinguishing true severe from pseudosevere stenosis and avoiding underestimation or delayed surgery in paradoxical low flow.
Key Points
- This paper reviews the complexities of diagnosing and managing low-flow, low-gradient aortic stenosis in patients with either preserved or depressed left ventricular ejection fraction.
- Literature review on diagnostic and therapeutic management strategies for LF-LG aortic stenosis.
- Discussion of distinguishing between true severe and pseudosevere stenosis.
- Examination of diagnostic tests beyond Doppler echocardiography.
- Highlighted the importance of accurate diagnosis to prevent mismanagement of aortic stenosis severity.
- Described the phenomenon of paradoxical LF-LG severe aortic stenosis with preserved left ventricular ejection fraction.
- Emphasized the need for timely surgical intervention to improve patient outcomes.
Structured PICO
P
Population
Patients with low-flow, low-gradient (LF-LG) aortic stenosis (AS) with normal and depressed left ventricular ejection fraction (LVEF)
This review outlines the diagnostic and therapeutic management of low-flow, low-gradient aortic stenosis, emphasizing the importance of distinguishing true severe from pseudosevere stenosis and recognizing paradoxical LF-LG severe AS.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
RARick A. NishimuraProfessor of cardiovascular diseases, Mayo Clinic
“I don't know why, but we're seeing more and more of these patients. I think 10 years ago we just kind of ignored them. We thought we'd made a mistake in our calculations. But in fact if you're very meticulous about your calculations, 30%-40% of your aortic stenosis patients fit into this category.”
“is a clinical condition that is frequently accompanied by comorbidities that inherently have an impact on prognosis and may explain, at least in part, the worse outcome observed.”
“Stroke volume is a crucial piece of information to determine prognosis and inform treatment decisions. It may be particularly important in symptomatic patients with low gradient, in whom decision-making with regard to valve replacement is more difficult.”
Implication
Distinguishing true from pseudosevere LF-LG AS prevents mismanagement; leaves open AVR benefit in preserved LVEF with restrictive physiology.
Abstract
Low-flow, low-gradient (LF-LG) aortic stenosis (AS) may occur with depressed or preserved left ventricular ejection fraction (LVEF), and both situations are among the most challenging encountered in patients with valvular heart disease. In both cases, the decrease in gradient relative to AS severity is due to a reduction in transvalvular flow. The main challenge in patients with depressed LVEF is to distinguish between true severe versus pseudosevere stenosis and to accurately assess the severity of myocardial impairment. Paradoxical LF-LG severe AS despite a normal LVEF is a recently described entity that is characterized by pronounced LV concentric remodeling, small LV cavity size, and a restrictive physiology leading to impaired LV filling, altered myocardial function, and worse prognosis. Until recently, this entity was often misdiagnosed, thereby causing underestimation of AS severity and inappropriate delays for surgery. Hence, the main challenge in these patients is proper diagnosis, often requiring diagnostic tests other than Doppler echocardiography. The present paper proposes to review the diagnostic and therapeutic management specificities of LF-LG AS with and without depressed LV function.
Discussion
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Cite This Study
Pîbarot et al. (2012) conducted a review in Low-flow, low-gradient aortic stenosis. Diagnostic evaluation of low-flow, low-gradient aortic stenosis requires distinguishing true severe from pseudosevere stenosis in depressed LVEF and identifying restrictive physiology in normal LVEF.