Heartbeat: Go with the flow in aortic stenosis?

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Aortic valve stenosis (AS), at the simplest level, is mechanical obstruction to left ventricular (LV) outflow with severity best described by the high velocity or pressure gradient across the valve or the small valve opening area. More recently, the importance of adverse left ventricular (LV) changes in patients with aortic valve disease has led to a new classification of AS to include measures of LV function and volume flow rate as follows: (1) high gradient severe AS with a transvalvular velocity ≥4 m/s or mean gradient ≥40 mm Hg, (2) low-flow low-gradient severe AS with reduced ejection fraction (<50%), and (3) low-flow low-gradient severe AS with normal ejection fraction and a stroke volume index ≤35 ml/m2.

In this issue of Heart, Capoulade and colleagues (see page 934) examined the differential value of measures of AS severity versus LV function for prediction of valve-related events and for all cause mortality in a consecutive series of 1065 patients with AS undergoing echocardiography. At baseline, 53% had severe AS, 17% had a low LV ejection fraction and 34% had a low stroke volume index. The findings confirm previous studies showing that parameters of AS severity, including maximum velocity, mean gradient and valve area, are the strongest predictors of valve related events (figure 1). However, the only multivariate predictors of all cause mortality were LV …

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