Skip to main content
SpringerLink
Log in

Hemodynamics of paradoxical severe aortic stenosis: insight from a pressure–volume loop analysis

  • Original Paper
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript

Abstract

Background

Controversy exists about the pathophysiology of different hemodynamic subgroups of AS. In particular, the mechanism of the paradoxical low-flow, low-gradient (PLFLG) AS with preserved ejection fraction (EF) is unclear.

Methods

A total of 41 patients with severe, symptomatic AS were divided into the following 4 subgroups based on the echocardiographically determined hemodynamics: (1) normal-flow, high-gradient (NFHG) AS; (2) low-flow, high-gradient AS; (3) paradoxical low-flow, low-gradient (PLFLG) AS with preserved EF and (4) low-flow, low-gradient (LFLG) AS with reduced EF. As part of the comprehensive invasive examinations, the analyses of the PV loops were performed with the IntraCardiac Analyzer (CD-Leycom, The Netherlands).

Results

PLFLG was characterized by small left ventricular volumes as well as a decreased cardiac index, a decreased systolic contractility and a lower stroke work, than the conventional NFHG AS. Alterations in effective arterial elastance (2.36 ± 0.67 mmHg/ml in NFHG versus 3.01 ± 0.79 mmHg/ml in PLFLG, p = 0.036) and end-systolic elastance (3.72 ± 1.84 mmHg/ml in NFHG versus 5.53 ± 2.3 mmHg/ml in PLFLG, p = 0.040) indicated impaired vascular function and increased chamber stiffness.

Conclusions

The present study suggests that the hemodynamics of PLFLG AS can be explained by two mechanisms: (1) stiffness of the small left ventricle with reduced contractility, and (2) increased afterload due to the impairment of vascular function. Both mechanisms have similarities to those of heart failure with preserved EF. This type of remodeling may explain the poor prognosis of PLFLG AS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Abbreviations

AS:

Aortic valve stenosis

AVA:

Aortic valve area

BNP:

B-type natriuretic peptide

EF:

Ejection fraction

HFpEF:

Heart failure with preserved ejection fraction

LFLG:

Low-flow, high-gradient

NFHG:

Normal-flow, high-gradient

PLFLG:

Paradoxical low-flow, low-gradient

SVI:

Stroke volume index

\(\tau\) :

Relaxation time constant

References

  1. Kim WK, Hamm CW (2018) Transcatheter aortic valve implantation in Germany. Clin Res Cardiol 107(Suppl 2):81–87

    Article  PubMed  Google Scholar 

  2. Doenst T, Kirov H, Moschovas A et al (2018) Cardiac surgery 2017 reviewed. Clin Res Cardiol 107(12):1087–1102. https://doi.org/10.1007/s00392-018-1280-9 (PMID: 29777372)

    Article  PubMed  Google Scholar 

  3. Nishimura RA, Otto CM, Bonow RO, American College of Cardiology/American Heart Association Task Force on Practice Guidelines et al (2014) AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 63:2438–2488

    Article  Google Scholar 

  4. Otto CM, Prendergast B (2014) Aortic-valve stenosis—from patients at risk to severe valve obstruction. N Engl J Med 371:744–756

    Article  CAS  PubMed  Google Scholar 

  5. Clavel MA, Magne J, Pibarot P (2016) Low-gradient aortic stenosis. Eur Heart J 37:2645–2657

    Article  PubMed  PubMed Central  Google Scholar 

  6. Jander N, Minners J, Holme I et al (2011) Outcome of patients with low-gradient “severe” aortic stenosis and preserved ejection fraction. Circulation 123:887–895 (Erratum in: Circulation. 2011;124:e336)

    Article  PubMed  Google Scholar 

  7. Chhabra L (2016) Inconsistency of hemodynamic data in low-gradient severe aortic stenosis. J Am Coll Cardiol 67:2446–2447

    Article  PubMed  Google Scholar 

  8. Clavel MA, Dumesnil JG, Capoulade R, Mathieu P, Sénéchal M, Pibarot P (2012) Outcome of patients with aortic stenosis, small valve area, and low-flow, low-gradient despite preserved left ventricular ejection fraction. J Am Coll Cardiol 60:1259–1267

    Article  PubMed  Google Scholar 

  9. Dayan V, Vignolo G, Magne J, Clavel MA, Mohty D, Pibarot P (2015) Outcome and impact of aortic valve replacement in patients with preserved LVEF and low-gradient aortic stenosis. J Am Coll Cardiol 66:2594–2603

    Article  PubMed  Google Scholar 

  10. Chin CWL, Ding ZP, Lam CSP, Ling LH (2016) Paradoxical low-gradient aortic stenosis: the HFpEF of aortic stenosis. J Am Coll Cardiol 67:2447–2448

    Article  PubMed  Google Scholar 

  11. Borlaug BA, Kass DA (2009) Invasive hemodynamic assessment in heart failure. Heart Fail Clin 5:217–228

    Article  PubMed  PubMed Central  Google Scholar 

  12. Baumgartner H, Hung J, Bermejo J et al (2017) Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 30:372–392

    Article  PubMed  Google Scholar 

  13. Lang RM, Badano LP, Mor-Avi V et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28:1–39.e14

    Article  Google Scholar 

  14. Lancellotti P, Tribouilloy C, Hagendorff A, Scientific Document Committee of the European Association of Cardiovascular Imaging et al (2013) Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 14:611–644

    Article  Google Scholar 

  15. Briand M, Dumesnil JG, Kadem L et al (2005) Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment. J Am Coll Cardiol 46:291–298

    Article  PubMed  Google Scholar 

  16. Baan J, Jong TT, Kerkhof PL et al (1981) Continuous stroke volume and cardiac output from intra-ventricular dimensions obtained with impedance catheter. Cardiovasc Res 15:328–334

    Article  CAS  PubMed  Google Scholar 

  17. Baan J, van der Velde ET, de Bruin HG et al (1984) Continuous measurement of left ventricular volume in animals and humans by conductance catheter. Circulation 70:812–823

    Article  CAS  PubMed  Google Scholar 

  18. ten Brinke EA, Klautz RJ, Verwey HF et al (2010) Single-beat estimation of the left ventricular end-systolic pressure-volume relationship in patients with heart failure. Acta Physiol (Oxf) 198:37–46

    Article  CAS  Google Scholar 

  19. Burkhoff D, Mirsky I, Suga H (2005) Assessment of systolic and diastolic ventricular properties via pressure-volume analysis: a guide for clinical, translational, and basic researchers. Am J Physiol Heart Circ Physiol 289:H501–H512

    Article  CAS  PubMed  Google Scholar 

  20. Tribouilloy C, Lévy F, Rusinaru D et al (2009) Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. J Am Coll Cardiol 53:1865–1873

    Article  PubMed  Google Scholar 

  21. Schymik G, Tzamalis P, Herzberger V et al (2017) Transcatheter aortic valve implantation in patients with a reduced left ventricular ejection fraction: a single-centre experience in 2000 patients (TAVIK Registry). Clin Res Cardiol 106:1018–1025

    Article  PubMed  Google Scholar 

  22. Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P (2007) Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 115:2856–2864

    Article  PubMed  Google Scholar 

  23. Zheng Q, Djohan AH, Lim E et al (2017) Effects of aortic valve replacement on severe aortic stenosis and preserved systolic function: systematic review and network meta-analysis. Sci Rep 7:5092

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Adda J, Mielot C, Giorgi R et al (2012) Low-flow, low-gradient severe aortic stenosis despite normal ejection fraction is associated with severe left ventricular dysfunction as assessed by speckle-tracking echocardiography: a multicenter study. Circ Cardiovasc Imaging 5:27–35

    Article  PubMed  Google Scholar 

  25. Herrmann S, Störk S, Niemann M et al (2011) Low-gradient aortic valve stenosis myocardial fibrosis and its influence on function and outcome. J Am Coll Cardiol 58:402–412

    Article  PubMed  Google Scholar 

  26. Kawaguchi M, Hay I, Fetics B, Kass DA (2003) Combined ventricular systolic and arterial stiffening in patients with heart failure and preserved ejection fraction: implications for systolic and diastolic reserve limitations. Circulation 107:714–720

    Article  PubMed  Google Scholar 

  27. Borlaug BA, Paulus WJ (2011) Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. Eur Heart J 32:670–679

    Article  PubMed  Google Scholar 

  28. Gotzmann M (2018) Renin-angiotensin system blockade after TAVI: is there a link between regression of left ventricular hypertrophy and prognosis? Heart 104:628–629

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

This work was supported by the German Heart Foundation/German Foundation of Heart Research (F/32/12).

Author information

Authors and Affiliations

  1. Cardiovascular Center, St. Josef Hospital Bochum, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany

    Michael Gotzmann, Maximilian Hogeweg & Andreas Mügge

  2. Department of Cardiology, Marien Hospital Witten, Ruhr University Bochum, Witten, Germany

    Sabine Hauptmann, Dinah S. Choudhury & Martin Bergbauer

  3. Cardiology and Angiology, Bergmannsheil, Ruhr University Bochum, Bochum, Germany

    Fabian Schiedat

  4. Department of Internal Medicine, Bergmannsheil, Ruhr University Bochum, Bochum, Germany

    Johannes W. Dietrich

  5. Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany

    Timm H. Westhoff

Authors
  1. Michael Gotzmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sabine Hauptmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Maximilian Hogeweg
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dinah S. Choudhury
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Fabian Schiedat
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Johannes W. Dietrich
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Timm H. Westhoff
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Martin Bergbauer
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Andreas Mügge
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael Gotzmann.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 12 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gotzmann, M., Hauptmann, S., Hogeweg, M. et al. Hemodynamics of paradoxical severe aortic stenosis: insight from a pressure–volume loop analysis. Clin Res Cardiol 108, 931–939 (2019). https://doi.org/10.1007/s00392-019-01423-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00392-019-01423-z

Keywords

Search

Navigation