Key result
Low-gradient severe aortic stenosis encompasses heterogeneous clinical entities with varying prognoses, requiring multimodality imaging for diagnosis and individualized treatment.
Why the study?
Up to 40% of patients with severe aortic stenosis display a discrepancy between valve area and gradient, representing heterogeneous clinical entities with distinct pathophysiological mechanisms.
Low-gradient severe aortic stenosis encompasses heterogeneous phenotypes requiring multimodality imaging for diagnosis, with classical and paradoxical low-flow variants warranting surgical or percutaneous intervention per guidelines.
Supports multimodality imaging for heterogeneous low-gradient aortic stenosis; leaves open optimal individualized treatment pathways.
Aortic stenosis (AS) is defined as severe in the presence of: mean gradient ≥40 mmHg, peak aortic velocity ≥4 m/s, and aortic valve area (AVA) ≤1 cm2 (or an indexed AVA ≤0.6 cm2/m2). However, up to 40% of patients have a discrepancy between gradient and AVA, i.e. AVA ≤1 cm2 (indicating severe AS) and a moderate gradient: >20 and <40 mmHg (typical of moderate stenosis). This condition is called ‘low-gradient AS’ and includes very heterogeneous clinical entities, with different pathophysiological mechanisms. The diagnostic tools needed to discriminate the different low-gradient AS phenotypes include colour-Doppler echocardiography, dobutamine stress echocardiography, computed tomography scan for the definition of the calcium score, and recently magnetic resonance imaging. The prognostic impact of low-gradient AS is heterogeneous. Classical low-flow low-gradient AS [reduced left ventricular ejection fraction (LVEF)] has the worst prognosis, followed by paradoxical low-flow low-gradient AS (preserved LVEF). Conversely, normal-flow low-gradient AS is associated with a better prognosis. The indications of the guidelines recommend surgical or percutaneous treatment, depending on the risk and comorbidities of the individual patient, both for patients with classic low-flow low-gradient AS and for those with paradoxical low-flow low-gradient AS.
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Vittoria Rizzello (2021) conducted a review in Moderate gradient severe aortic stenosis (low-gradient AS). Low-gradient severe aortic stenosis encompasses heterogeneous clinical entities with varying prognoses, requiring multimodality imaging for diagnosis and individualized treatment.
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