Flow-Gradient Patterns in Severe Aortic Stenosis With Preserved Ejection Fraction Clinical Characteristics and Predictors of Survival Mackram F. Eleid, MD; Paul Sorajja, MD; Hector I. Michelena, MD Joseph F. Malouf, MD; Christopher G. Scott, MS; Patricia A. Pellikka, MD Circulation. October 15, 2013;128: R3 변종규 / prof. 하상진

Introduction severe AS –aortic valve area (AVA) <1 cm 2 –mean systolic Doppler gradient ≥40 mm Hg –a peak aortic velocity ≥4 m/s Stroke volume is an important determinant of the aortic valve gradient. To further define the hemodynamic features of severe AS, => flow-gradient classification has been proposed that incorporates both mean gradient and stroke volume 2

Syndrome of low-gradient (LG) severe AS and preserved ejection fraction (EF), called paradoxical low-flow (LF)/LG severe AS. These conditions have importance => they may be associated with a poor prognosis. To determine the clinical characteristics and long-term outcome of patients with severe AS and preserved EF according to stroke volume and aortic valve gradient. 3

Patients –The Mayo Clinic, between January 1, 2006, and December 31, 2011 Inclusion criteria –≥18 years of age who underwent transthoracic echocardiography –AVA <1.0 cm 2, preserved left ventricular (LV) EF (≥50%), Exclusion criteria –prosthetic valves –complex congenital heart disease –supravalvular or subvalvular AS –hypertrophic cardiomyopathy –other moderate or severe native valvular lesions 4 Methods

5 14,656 with AS underwent TTE 1,704 included 9,558 excluded for AVA >1 cm 2 9,558 excluded for AVA >1 cm 2 2,231 excluded for EF <50% 2,231 excluded for EF <50% 1,156 excluded for ≥1 valvular heart lesions 1,156 excluded for ≥1 valvular heart lesions 2 - supravalvular AS 5 - subaortic stenosis 2 - supravalvular AS 5 - subaortic stenosis

RESULTS 6

7

8

9

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11 LF/LG 60% NF/HG 85% NF/LG 82%

12 NF/LG LF/HG

13 NF/LG 82%

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15

Conclusion NF/LG severe AS with preserved ejection fraction exhibits favorable survival with medical management. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure, and reduced survival, and aortic valve replacement was associated with improved survival. These findings have implications for the evaluation and subsequent management of AS severity 16