Author + information
- Received September 28, 2015
- Revision received February 29, 2016
- Accepted March 3, 2016
- Published online January 2, 2017.
- Candelas Pérez del Villar, MD, PhD,
- Raquel Yotti, MD, PhD∗ (, )
- María Ángeles Espinosa, MD, PhD,
- Enrique Gutiérrez-Ibañes, MD, PhD,
- Alicia Barrio, DCS, MBiol,
- María José Lorenzo, BSN,
- Pedro Luis Sánchez Fernández, MD, PhD,
- Yolanda Benito, DCS, DVM,
- Raquel Prieto, MD, PhD,
- Esther Pérez David, MD, PhD,
- Pablo Martínez-Legazpi, MEng, PhD,
- Francisco Fernández-Avilés, MD, PhD and
- Javier Bermejo, MD, PhD
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense de Madrid, Spain
- ↵∗Reprint requests and correspondence:
Dr. Raquel Yotti, Department of Cardiology, Hospital General Universitario Gregorio Marañón, Dr. Esquerdo 46, 28007 Madrid, Spain.
Objectives The goal of this study was to determine the functional impact of paradoxical low-gradient aortic stenosis (PLGAS) and clarify whether the relevance of the valvular obstruction is related to baseline flow.
Background Establishing the significance of PLGAS is particularly challenging.
Methods Twenty symptomatic patients (77 ± 6 years of age; 17 female subjects) with PLGAS (mean gradient 28 ± 6 mm Hg; aortic valve area 0.8 ± 0.1 cm2; ejection fraction 66 ± 7%) underwent cardiopulmonary exercise testing combined with right-heart catheterization and Doppler echocardiographic measurements.
Results Aortic valve area increased by 84 ± 23% (p < 0.001) and, in 70% of subjects, it reached values >1.0 cm2 at peak exercise. Stroke volume index and blood pressure increased by 83 ± 56% and 26 ± 16%, respectively (both p < 0.0001). Peak oxygen consumption inversely correlated with the rate of increase in pulmonary capillary wedge pressure (PCWP) (PCWP slope: R = –0.61; p = 0.004). In turn, the PCWP slope was determined by changes in the valvular and vascular load but not by the rest of the indices of aortic stenosis. The functional impact of PLGAS was also not related to baseline flow. Agreement between Doppler echocardiography and the Fick technique was good up to intermediate workload.
Conclusions In symptomatic patients with PLGAS, the capacity to dynamically reduce vascular and valvular loads determines the effect of exercise on PCWP, which, in turn, conditions the functional status. A critically fixed valvular obstruction may not be the main mechanism of functional impairment in a large proportion of patients with PLGAS. Exercise echocardiography is suitable to study the dynamics of PLGAS.
This study was supported by grants PIS09/02602, PIS012/02878, and RD12/0042 (Red de Investigación Cardiovascular), FI11/00700 (Dr. Espinosa), and CM12/00273 (Dr. Pérez del Villar) from the Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, Spain, and by the EU–European Regional Development Fund. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 28, 2015.
- Revision received February 29, 2016.
- Accepted March 3, 2016.
- American College of Cardiology Foundation