title: Outcome and impact of surgery in paradoxical low-flow, low-gradient severe aortic stenosis and preserved left ventricular ejection fraction: a cardiac catheterization study.
abstract: BACKGROUND
  The clinical relevance and management of paradoxical low-flow, low-gradient aortic stenosis (LFLG-AS) with preserved left ventricular ejection fraction remain debated. The aim of this study is to determine the features and outcome of LFLG-AS assessed using cardiac catheterization.
  
  
  RESULTS
  Between 2000 and 2010, 768 patients with preserved left ventricular ejection fraction (>50%) and severe AS (valve area ≤ 1 cm(2)) without other valvular disease underwent cardiac catheterization. Mean age was 74 ± 8 years, 42% were women, and 46% had associated coronary artery disease. The prevalence of LFLG (indexed left ventricular stroke volume <35 mL/m(2) and mean gradient <40 mm Hg), normal flow high gradient, normal flow low gradient, and low flow high gradient were 13%, 50%, 22%, and 15%, respectively. Compared with patients with normal flow high gradient, those with LFLG were significantly older, with significantly reduced systemic arterial compliance and vascular resistances and increased valvulo-arterial impedance (all P<0.05). Ten-year survival was reduced in LFLG-AS (32 ± 9%) compared with normal flow high gradient (66 ± 4%; P=0.0002). After adjustment for other risk factors, LFLG-AS was independently associated with reduced long-term survival (hazard ratio, 1.85; 95% confidence interval, 1.08-3.07; P=0.02). However, despite higher operative mortality, patients with LFLG-AS undergoing aortic valve replacement seemed to have better long-term survival than those managed conservatively (5-year survival rate: 63 ± 6% versus 38 ± 15%; P=0.007; hazard ratio, 0.23; 95% confidence interval, 0.09-0.59; P=0.002).
  
  
  CONCLUSIONS
  This large cardiac catheterization-based study reports that the LFLG-AS entity is not rare and is associated with worse outcome whether treated medically or surgically. However, these patients may have better long-term survival if treated surgically. Further prospective studies are needed to confirm this finding.
authors.affiliation: CHU Limoges, Hôpital Dupuytren, Pôle Cœur-Poumon-Rein, Service Cardiologie, Limoges, France (D.M., M.D., V.A., N.E., C.C., M.L., P.V.); Department of Cardiology, GIGA Cardiovascular Sciences, Heart Valve Clinic, University of Liège, CHU Sart-Tilman, Liège, Belgium (J.M.); Inserm U1094, Tropical Neuroepidemiology, Limoges, France (V.A.); Department of Medicine, Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (P.P.).
authors.forename: Dania
authors.initials: D
authors.lastname: Mohty
authors.forename: Julien
authors.initials: J
authors.lastname: Magne
authors.forename: Mathieu
authors.initials: M
authors.lastname: Deltreuil
authors.forename: Victor
authors.initials: V
authors.lastname: Aboyans
authors.forename: Najmeddine
authors.initials: N
authors.lastname: Echahidi
authors.forename: Claude
authors.initials: C
authors.lastname: Cassat
authors.forename: Philippe
authors.initials: P
authors.lastname: Pibarot
authors.forename: Marc
authors.initials: M
authors.lastname: Laskar
authors.forename: Patrice
authors.initials: P
authors.lastname: Virot
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D001783:Blood Flow Velocity / Q000502:physiology*; D006328:Cardiac Catheterization / Q000401:mortality / Q000639:trends*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000502:physiology*; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology*
keywords: LV function; aortic stenosis; catheterization; surgery; survival; valve