“Pure” severe aortic stenosis without concomitant valvular heart diseases: echocardiographic and pathophysiological features

Figures

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  Fig. 1. Flow chart of the selection criteria defining “pure” AS patients. AS = Aortic stenosis; EOA = Effective Orifice Area; AR = Aortic valve regurgitation; MR = Mitral regurgitation; TR = Tricuspid regurgitation

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  Fig. 2. Assessment of effective Aortic orifice Valve Area (AVA) by continuity equation (a-c) and determination of left ventricular stroke volume (LVSV) by Doppler method (a,c) and by Simpson’s method (d-k). LV = left ventricle, LVOT = left ventricular outflow tract, 2C = 2-chamber, 4C = 4-chamber, SV = stroke volume, ESV = end-systolic volume, EDV = end-diastolic volume, EF = ejection fraction, Vmax = maximum flow velocity, maxPG = maximum pressure gradient, meanPG = mean pressure gradient VTI = velocity time integral, CO = cardiac output, HR = heart rate, CI = cardiac index, SI = stroke index

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  Fig. 3. Determination of left ventricular hypertrophy (a), diastolic dysfunction (b-f) and pulmonary arterial hypertension (f) by echocardiography. IVSd = diameter of interventricular septum, LVIDd = left ventricular internal dimension at end-diastole, LVPWd = left ventricular posterior wall diameter, LAEDV = left atrial end diastolic volume, TR = tricuspid regurgitation, Vmax = maximum velocity, maxPG = maximum pressure gradient, MV = mitral valve

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  Fig. 4. Circle diagram to illustrate the intersections between the presence of maxVAV > 4.0 m/s, mPGAV > 40mmHG, and maxVLVOT/maxVAV in patients with “pure” severe AS defined by EOA < 0.6 cm2/m2 according to current guidelines: EOA < 0.6 cm2/m2 was documented in 113 “pure” AS patients without either a significant increase of maxVAV or mPGAV or a decrease of maxVLVOT/maxVAV. maxVAV = peak transvalvular flow velocity; mPGAV = mean transvalvular pressure gradient; maxVLVOT/maxVAV = ratio between peak velocity determined at the level of LV outflow tract (maxVLVOT) and maxVAV

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  Fig. 5. Selection of the study population with respect to mPGAV and SVi. Patients were divided according to the ESC/EACTS guidelines for the management of valvular heart disease (2017). AS = Aortic stenosis; LG = low gradient; HG = high gradient; LFLG = low flow low gradient; NFLG = normal flow low gradient; LFHG = low flow high gradient; NFHG = normal flow high gradient; SVi = stroke volume index; mPGAV = mean pressure gradient of the aortic valve; LV = left ventricle; EF = ejection fraction

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  Fig. 6. Selection of the study population with respect to diastolic dysfunction. SR = Sinus rhythm, AF = Atrial fibrillation; LAVI = indexed left atrial volume; TR = Tricuspid regurgitation; LAP = Left atrial pressure

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  Fig. 7. Retrospective data analysis in patients with “pure” severe AS until december 2019. AS = Aortic stenosis; TAVI = transcatheter aortic valve implantation