title: Differential left ventricular remodelling and longitudinal function distinguishes low flow from normal-flow preserved ejection fraction low-gradient severe aortic stenosis.
abstract: OBJECTIVE
  There is uncertainty in identifying patients with severe aortic stenosis (AS) with preserved left ventricular (LV) ejection fraction, low flow, and low gradients (LFLG). Prior studies propose that these patients demonstrate significant concentric remodelling and decreased survival, while others suggest that they have features and survival similar to moderate AS.
  
  
  RESULTS
  We compared the clinical characteristics, echocardiographic features, and overall survival of LFLG AS patients (n = 38) to those with normal-flow, low-gradient (NFLG) severe AS (n = 75) and moderate AS (n = 70). Low-flow, low-gradient patients had the lowest end-diastolic volume index (43 vs. 54 vs. 54 mL/m², P < 0.001), highest relative wall thickness (RWT) (60 vs. 49 vs. 48%, P < 0.001), and lowest septal mitral annular displacement (1.0 vs. 1.5 vs. 1.5 cm, P < 0.001). New York Heart Association (NYHA) class III/IV symptoms were the most frequent in the LFLG group (29 vs. 11 vs. 3%, P < 0.001). Survival at 3 years was significantly lower in LFLG compared with NFLG (P = 0.006) and moderate AS (P = 0.002), but not different between NFLG and moderate AS (P = 0.49). Higher NYHA classification (HR 1.77, 95% CI 1.22-2.57), RWT > 50% (HR 3.28, 95% CI 1.33-8.1), and septal displacement <1.1 cm (HR 3.93, 95% CI 1.96-7.82) but not low flow were independent predictors of survival in Cox proportional hazards analysis.
  
  
  CONCLUSIONS
  Preserved ejection fraction, LFLG AS patients exhibit marked concentric remodelling and impaired longitudinal functional-features that predict their poor long-term survival. Normal-flow, low-gradient AS patients have outcomes similar to moderate AS.
authors.affiliation: Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
authors.forename: Praveen
authors.initials: P
authors.lastname: Mehrotra
authors.forename: Katrijn
authors.initials: K
authors.lastname: Jansen
authors.forename: Aidan W
authors.initials: AW
authors.lastname: Flynn
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Tan
authors.forename: Sammy
authors.initials: S
authors.lastname: Elmariah
authors.forename: Michael H
authors.initials: MH
authors.lastname: Picard
authors.forename: Judy
authors.initials: J
authors.lastname: Hung
mesh_terms: D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D012189:Retrospective Studies; D013318:Stroke Volume / Q000502:physiology; D018487:Ventricular Dysfunction, Left / Q000401:mortality / Q000503:physiopathology; D020257:Ventricular Remodeling / Q000502:physiology*
keywords: Aortic stenosis; Echocardiography; Haemodynamics; Remodelling