title: Right Ventricular Function and Prognosis in Patients with Low-Flow, Low-Gradient Severe Aortic Stenosis.
abstract: BACKGROUND
  Patients with low left ventricular ejection fractions and low-flow, low-gradient aortic stenosis (AS) represent a challenging cohort with high morbidity and mortality. The prevalence and clinical impact of right ventricular dysfunction (RVD) on risk stratification and prognosis in these patients is unknown.
  
  
  METHODS
  A retrospective analysis was performed of 65 patients with low-flow, low-gradient AS who underwent low-dose dobutamine stress echocardiography to determine AS severity and to ascertain flow reserve status (≥20% stroke volume increase). Clinical, demographic, and imaging data were prospectively collected. Per guidelines, RVD was defined as tricuspid annular plane systolic excursion < 16 mm in the apical four-chamber view and measured at baseline. Cox proportional hazards modeling was used to risk-adjust comparisons for the end point of all-cause mortality.
  
  
  RESULTS
  The mean age was 74 ± 9 years, the mean left ventricular ejection fraction was 29 ± 10%, the mean indexed aortic valve (AV) area was 0.49 ± 0.1 cm(2)/m(2), and the mean AV gradient 22 ± 7 mm Hg. RVD was present in 37 patients (57% of the study cohort). After a median follow-up period of 13 months (interquartile range, 5-30 months), there were 29 AV replacements and 30 deaths. The presence of RVD (hazard ratio, 2.86; 95% CI, 1.21-6.75; P = .02) was an independent risk factor associated with all-cause mortality despite many adjustments for potential clinical and echocardiographic confounders such as AV replacement, Society of Thoracic Surgeons Predicted Risk of Mortality score, severity of tricuspid regurgitation, and left ventricular global longitudinal strain.
  
  
  CONCLUSIONS
  Baseline RVD is prevalent in patients with low-flow, low-gradient AS undergoing dobutamine stress echocardiography. Quantification of right ventricular systolic function in these complex patients provides important prognostic value and risk stratification adjunctive to Society of Thoracic Surgeons Predicted Risk of Mortality score and should be incorporated into the decision-making process.
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Electronic address: cavalcantejl@upmc.edu.
authors.forename: João L
authors.initials: JL
authors.lastname: Cavalcante
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Shasank
authors.initials: S
authors.lastname: Rijal
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Althouse
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Antonia
authors.initials: A
authors.lastname: Delgado-Montero
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: William E
authors.initials: WE
authors.lastname: Katz
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: John T
authors.initials: JT
authors.lastname: Schindler
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Frederick
authors.initials: F
authors.lastname: Crock
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Harinstein
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Forozan
authors.initials: F
authors.lastname: Navid
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Gleason
authors.affiliation: Department of Medicine, Division of Cardiovascular Diseases Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Joon S
authors.initials: JS
authors.lastname: Lee
mesh_terms: D000368:Aged; D001024:Aortic Valve Stenosis / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology; D002423:Cause of Death / Q000639:trends; D004452:Echocardiography / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005961:Glucosinolates; D006352:Heart Ventricles / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006801:Humans; D008297:Male; D010414:Pennsylvania / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000502:physiology; D015996:Survival Rate / Q000639:trends; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D016278:Ventricular Function, Right / Q000502:physiology*
chemical_list: D005961:Glucosinolates; C009048:progoitrin
keywords: Low-flow, low-gradient aortic stenosis; Prognosis; Right ventricular function