Skip to main content
SpringerLink
Log in

Assessment of Aortic Stenosis Severity: Determining Timing to Surgery

  • Chapter
  • First Online:
Cardiac Valvular Medicine

  • 1614 Accesses

Abstract

“Degenerative” or calcific aortic stenosis (AS) is a complex, multi-faceted, and systemic disease that is not solely limited to the aortic valve but also includes reduced arterial compliance as well as alteration of LV geometry and function. This particular nature of the disease underlines the need for a more comprehensive assessment of AS severity going beyond the simple measurement of the conventional parameters of stenosis severity (i.e. peak aortic jet velocity, pressure gradients, valve effective orifice area) or LV function (i.e. LVEF). The present chapter thus proposes to review newer concepts to quantify the disease severity taking into account the inter-relation between the different valvular, arterial, and ventricular variables that may be responsible for the appearance of symptoms or poorer prognosis in patients with AS.

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

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 159.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  • Alborino D, Hoffmann JL, Fournet PC, Bloch A. Value of exercise testing to evaluate the indication for surgery in asymptomatic patients with valvular aortic stenosis. J Heart Valve Dis. 2002;11:204–9.

    PubMed  Google Scholar 

  • Amato MC, Moffa PJ, Werner KE, Ramires JA. Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing. Heart. 2001;86:381–6.

    Article  PubMed  CAS  Google Scholar 

  • Antonini-Canterin F, Huang G, Cervesato E, et al. Symptomatic aortic stenosis: does systemic hypertension play an additional role? Hypertension. 2003;41:1268–72.

    Article  PubMed  CAS  Google Scholar 

  • Azevedo CF, Nigri M, Higuchi ML, et al. Prognostic significance of myocardial fibrosis quantification by histopathology and magnetic resonance imaging in patients with severe aortic valve disease. J Am Coll Cardiol. 2010;56:278–87.

    Article  PubMed  Google Scholar 

  • Bahlmann E, Cramariuc D, Gerdts E, et al. Impact of pressure recovery on echocardiographic assessment of asymptomatic aortic stenosis: a SEAS Substudy. JACC Cardiovasc Imaging. 2010;3:555–62.

    Article  PubMed  Google Scholar 

  • Barasch E, Fan D, Chukwu EO, et al. Severe isolated aortic stenosis with normal left ventricular systolic function and low transvalvular gradients: pathophysiologic and prognostic insights. J Heart Valve Dis. 2008;17:81–8.

    PubMed  Google Scholar 

  • Baumgartner H, Steffenelli T, Niederberger J, Schima H, Maurer G. “Overestimation” of catheter gradients by Doppler ultrasound in patients with aortic stenosis: a predictable manifestation of pressure recovery. J Am Coll Cardiol. 1999;33:1655–61.

    Article  PubMed  CAS  Google Scholar 

  • Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr. 2009;22:1–23.

    Article  PubMed  Google Scholar 

  • Bergler-Klein J, Klaar U, Heger M, et al. Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis. Circulation. 2004;109:2302–8.

    Article  PubMed  CAS  Google Scholar 

  • Bergler-Klein J, Mundigler G, Pibarot P, et al. B-type natriuretic peptide in low-flow, low-gradient aortic stenosis: relationship to hemodynamics and clinical outcome. Circulation. 2007;115:2848–55.

    Article  PubMed  CAS  Google Scholar 

  • Bermejo J, Odreman R, Feijoo J, Moreno MM, Gomez-Moreno P, Garcia-Fernandez MA. Clinical efficacy of Doppler-echocardiographic indices of aortic valve stenosis:a comparative test-based analysis of outcome. J Am Coll Cardiol. 2003;41:142–51.

    Article  PubMed  Google Scholar 

  • Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation. 2006;114:e84–231.

    Article  PubMed  Google Scholar 

  • Briand M, Dumesnil JG, Kadem L, et al. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: Implications for diagnosis and treatment. J Am Coll Cardiol. 2005;46:291–8.

    Article  PubMed  Google Scholar 

  • Briand M, Lemieux I, Dumesnil JG, et al. Metabolic syndrome negatively influences disease progression and prognosis in aortic stenosis. J Am Coll Cardiol. 2006;47:2229–36.

    Article  PubMed  Google Scholar 

  • Brown ML, Pellikka PA, Schaff HV, et al. The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis. J Thorac Cardiovasc Surg. 2008;135:308–15.

    Article  PubMed  Google Scholar 

  • Carabello BA. Aortic stenosis. N Engl J Med. 2002;346:677–82.

    Article  PubMed  Google Scholar 

  • Carroll JD, Carroll EP, Feldman T, et al. Sex-associated differences in left ventricular function in aortic stenosis of the elderly. Circulation. 1992;86:1099–107.

    Article  PubMed  CAS  Google Scholar 

  • Cioffi G, Faggiano P, Vizzardi E, et al. Prognostic value of inappropriately high left ventricular mass in asymptomatic severe aortic stenosis. Heart. 2011;97:301–7.

    Article  PubMed  Google Scholar 

  • Clavel MA, Fuchs C, Burwash IG, et al. Predictors of outcomes in low-flow, low-gradient aortic stenosis: results of the multicenter TOPAS Study. Circulation. 2008;118:S234–42.

    Article  PubMed  Google Scholar 

  • Clavel MA, Webb JG, Rodés-Cabau J, et al. Comparison between transcatheter and surgical prosthetic valve implantation in patients with severe aortic stenosis and reduced left ventricular ejection fraction. Circulation. 2010;122:1928–36.

    Article  PubMed  CAS  Google Scholar 

  • Cramariuc D, Cioffi G, Rieck AE, et al. Low-flow aortic stenosis in asymptomatic patients: valvular arterial impedance and systolic function from the SEAS substudy. JAAC Cardiovasc Imaging. 2009a;2:390–9.

    Article  Google Scholar 

  • Cramariuc D, Gerdts E, Davidsen ES, Segadal L, Matre K. Myocardial deformation in aortic valve stenosis - relation to left ventricular geometry. Heart. 2009b;96:106–12.

    Article  PubMed  Google Scholar 

  • Cueff C, Serfaty JM, Cimadevilla C, et al. Measurement of aortic valve calcification using multislice computed tomography: correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction. Heart. 2011;97:721–6.

    Google Scholar 

  • Das P, Rimington H, Chambers J. Exercise testing to stratify risk in aortic stenosis. Eur Heart J. 2005;26:1309–13.

    Article  PubMed  Google Scholar 

  • de Filippi CR, Willett DL, Brickner E, et al. Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low transvalvular gradients. Am J Cardiol. 1995;75:191–4.

    Article  Google Scholar 

  • Dumesnil JG, Shoucri RM. Quantitative relationships between left ventricular ejection and wall thickening and geometry. J Appl Physiol. 1991;70:48–54.

    PubMed  CAS  Google Scholar 

  • Dumesnil JG, Shoucri RM, Laurenceau JL, Turcot J. A mathematical model of the dynamic geometry of the intact left ventricle and its application to clinical data. Circulation. 1979;59:1024–34.

    Article  PubMed  CAS  Google Scholar 

  • Dumesnil JG, Pibarot P, Carabello B. Paradoxical low flow and/or low gradient severe aortic stenosis despite preserved left ventricular ejection fraction: implications for diagnosis and treatment. Eur Heart J. 2010;31:281–9.

    Article  PubMed  Google Scholar 

  • Duncan AI, Lowe BS, Garcia MJ, et al. Influence of concentric left ventricular remodeling on early mortality after aortic valve replacement. Ann Thorac Surg. 2008;85:2030–9.

    Article  PubMed  Google Scholar 

  • Garcia D, Pibarot P, Dumesnil JG, Sakr F, Durand LG. Assessment of aortic valve stenosis severity: A new index based on the energy loss concept. Circulation. 2000;101:765–71.

    Article  PubMed  CAS  Google Scholar 

  • Garcia D, Dumesnil JG, Durand LG, Kadem L, Pibarot P. Discrepancies between catheter and Doppler estimates of valve effective orifice area can be predicted from the pressure recovery phenomenon: practical implications with regard to quantification of aortic stenosis severity. J Am Coll Cardiol. 2003;41:435–42.

    Article  PubMed  Google Scholar 

  • Gerber IL, Stewart RA, Legget ME, et al. Increased plasma natriuretic peptide levels reflect symptom onset in aortic stenosis. Circulation. 2003;107:1884–90.

    Article  PubMed  Google Scholar 

  • Gerber IL, Legget ME, West TM, Richards AM, Stewart RA. Usefulness of serial measurement of N-terminal pro-brain natriuretic peptide plasma levels in asymptomatic patients with aortic stenosis to predict symptomatic deterioration. Am J Cardiol. 2005;95:898–901.

    Article  PubMed  CAS  Google Scholar 

  • Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P. Paradoxical low flow, low gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation. 2007;115:2856–64.

    Article  PubMed  Google Scholar 

  • Hachicha Z, Dumesnil JG, Pibarot P. Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis. J Am Coll Cardiol. 2009;54:1003–11.

    Article  PubMed  Google Scholar 

  • Herrmann S, Stork S, Niemann M, et al. Low-gradient aortic valve stenosis: myocardial fibrosis and its influence on function and outcome. J Am Coll Cardiol. 2011;58:402–12.

    Article  PubMed  Google Scholar 

  • Higgins J, Jamieson WR, Benhameid O, et al. Influence of patient gender on mortality after aortic valve replacement for aortic stenosis. J Thorac Cardiovasc Surg. 2011;142:595–601. 601.

    Article  PubMed  Google Scholar 

  • Jander N, Minners J, Holme I, et al. Outcome of patients with low-gradient “severe” aortic stenosis and preserved ejection fraction. Circulation. 2011;123:887–95.

    Google Scholar 

  • Kang DH, Park SJ, Rim JH, et al. Early surgery versus conventional treatment in asymptomatic very severe aortic stenosis. Circulation. 2010;121:1502–9.

    Article  PubMed  Google Scholar 

  • Katz R, Budoff MJ, Takasu J, et al. Relationship of metabolic syndrome to incident aortic valve calcium and aortic valve calcium progression: the multi-ethnic study of atherosclerosis (MESA). Diabetes. 2009;58:813–9.

    Article  PubMed  CAS  Google Scholar 

  • Lafitte S, Perlant M, Reant P, et al. Impact of impaired myocardial deformations on exercise tolerance and prognosis in patients with asymptomatic aortic stenosis. Eur J Echocardiogr. 2009;10:414–9.

    Article  PubMed  Google Scholar 

  • Lancellotti P, Lebois F, Simon M, Tombeux C, Chauvel C, Pierard LA. Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation. 2005;112:I377–82.

    PubMed  Google Scholar 

  • Lancellotti P, Donal E, Magne J, et al. Impact of global left ventricular afterload on left ventricular function in asymptomatic severe aortic stenosis: a two-dimensional speckle-tracking study. Eur J Echocardiogr. 2010a;11:537–43.

    Article  PubMed  Google Scholar 

  • Lancellotti P, Donal E, Magne J, et al. Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay. Heart. 2010b;96:1364–71.

    Article  PubMed  Google Scholar 

  • Lancellotti P, Moonen M, Magne J, et al. Prognostic effect of long-axis left ventricular dysfunction and B-type natriuretic peptide levels in asymptomatic aortic stenosis. Am J Cardiol. 2010c;105:383–8.

    Article  PubMed  CAS  Google Scholar 

  • Lund BP, Gohlke-Barwolf C, Cramariuc D, Rossebo AB, Rieck AE, Gerdts E. Effect of obesity on left ventricular mass and systolic function in patients with asymptomatic aortic stenosis (a Simvastatin Ezetimibe in Aortic Stenosis [SEAS] substudy). Am J Cardiol. 2010;105:1456–60.

    Article  PubMed  Google Scholar 

  • Maréchaux S, Hachicha Z, Bellouin A, et al. Usefulness of exercise stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. Eur Heart J. 2010;31:1390–7.

    Article  PubMed  Google Scholar 

  • Messika-Zeitoun D, Bielak LF, Peyser PA, et al. Aortic valve calcification: determinants and progression in the population. Arterioscler Thromb Vasc Biol. 2007;27:642–8.

    Article  PubMed  CAS  Google Scholar 

  • Mihaljevic T, Nowicki ER, Rajeswaran J, et al. Survival after valve replacement for aortic stenosis: implications for decision making. J Thorac Cardiovasc Surg. 2008;135:1270–8.

    Article  PubMed  Google Scholar 

  • Minners J, Allgeier M, Gohlke-Baerwolf C, Kienzle RP, Neumann FJ, Jander N. Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis. Eur Heart J. 2008;29:1043–8.

    Article  PubMed  Google Scholar 

  • Minners J, Allgeier M, Gohlke-Baerwolf C, Kienzle RP, Neumann FJ, Jander N. Inconsistent grading of aortic valve stenosis by current guidelines: haemodynamic studies in patients with apparently normal left ventricular function. Heart. 2010;96:1463–8.

    Article  PubMed  Google Scholar 

  • Monin JL, Quere JP, Monchi M, et al. Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics. Circulation. 2003;108:319–24.

    Article  PubMed  Google Scholar 

  • Monin JL, Lancellotti P, Monchi M, et al. Risk score for predicting outcome in patients with asymptomatic aortic stenosis. Circulation. 2009;120:69–75.

    Article  PubMed  Google Scholar 

  • Nazarian S. Is ventricular arrhythmia a possible mediator of the association between aortic stenosis-related midwall fibrosis and mortality? J Am Coll Cardiol. 2011;58:1280–2.

    Article  PubMed  Google Scholar 

  • Ng AC, Delgado V, Bertini M, et al. Alterations in multidirectional myocardial functions in patients with aortic stenosis and preserved ejection fraction: a two-dimensional speckle tracking analysis. Eur Heart J. 2011;32:1542–50.

    Article  PubMed  Google Scholar 

  • Nistri S, Grande-Allen J, Noale M, et al. Aortic elasticity and size in bicuspid aortic valve syndrome. Eur Heart J. 2008;29(4):472–9.

    Article  PubMed  Google Scholar 

  • Orsinelli DA, Aurigemma GP, Battista S, Krendel S, Gaasch WH. Left ventricular hypertrophy and mortality after aortic valve replacement for aortic stenosis. A high risk subgroup identified by preoperative relative wall thickness. J Am Coll Cardiol. 1993;22:1679–83.

    Article  PubMed  CAS  Google Scholar 

  • Otto CM. Valvular aortic stenosis: disease severity and timing of intervention. J Am Coll Cardiol. 2006;47:2141–51.

    Article  PubMed  Google Scholar 

  • Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation. 1997;95:2262–70.

    Article  PubMed  CAS  Google Scholar 

  • Pagé A, Dumesnil JG, Clavel MA, et al. Metabolic syndrome is associated with more pronounced impairment of LV geometry and function in patients with calcific aortic stenosis: a substudy of the ASTRONOMER trial. (Aortic Stenosis Progression Observation Measuring Effects of Rosuvastatin). J Am Coll Cardiol. 2010;55:1867–74.

    Article  PubMed  Google Scholar 

  • Pai RG, Varadarajan P, Razzouk A. Survival benefit of aortic valve replacement in patients with severe aortic stenosis with low ejection fraction and low gradient with normal ejection fraction. Ann Thorac Surg. 2008;86:1781–9.

    Article  PubMed  Google Scholar 

  • Pibarot P, Dumesnil JG. Improving assessment of aortic stenosis. J Am Coll Cardiol. 2012a (in press).

    Google Scholar 

  • Pibarot P, Dumesnil JG. Low-flow, low-gradient aortic stenosis in normal and depressed LV ejection fraction. J Am Coll Cardiol. 2012b (in press).

    Google Scholar 

  • Picano E, Pibarot P, Lancellotti P, Monin JL, Bonow RO. The emerging role of exercise testing and stress echocardiography in valvular heart disease. J Am Coll Cardiol. 2009;54:2251–60.

    Article  PubMed  Google Scholar 

  • Poulsen SH, Sogaard P, Nielsen-Kudsk JE, Egeblad H. Recovery of left ventricular systolic longitudinal strain after valve replacement in aortic stenosis and relation to natriuretic peptides. J Am Soc Echocardiogr. 2007;20:877–84.

    Article  PubMed  Google Scholar 

  • Rahimtoola SH. Determining that aortic valve stenosis is severe: back-to-the-future: physical examination and aortic valve area index/energy loss index 0.6 cm2/m2. JACC Cardiovasc Imaging. 2010;3:563–6.

    Article  PubMed  Google Scholar 

  • Rajamannan NM, Bonow RO, Rahimtoola SH. Calcific aortic stenosis: an update. Nat Clin Pract Cardiovasc Med. 2007;4:254–62.

    Article  PubMed  CAS  Google Scholar 

  • Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med. 2000;343:611–7.

    Article  PubMed  CAS  Google Scholar 

  • Rosenhek R, Zilberszac R, Schemper M, et al. Natural history of very severe aortic stenosis. Circulation. 2010;121:151–6.

    Article  PubMed  Google Scholar 

  • Ross Jr J, Braunwald E. Aortic stenosis. Circulation. 1968;38:61–7.

    Article  PubMed  Google Scholar 

  • Rossebo AB, Pedersen TR, Boman K, et al. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis. N Engl J Med. 2008;359:1343–56.

    Article  PubMed  Google Scholar 

  • Spevack DM, Almuti K, Ostfeld R, Bello R, Gordon GM. Routine adjustment of doppler echocardiographically derived aortic valve area using a previously derived equation to account for the effect of pressure recovery. J Am Soc Echocardiogr. 2008;21:34–7.

    Article  PubMed  Google Scholar 

  • Steadman CD, Ray S, Ng LL, McCann GP. Natriuretic peptides in common valvular heart disease. J Am Coll Cardiol. 2010;55:2034–48.

    Article  PubMed  CAS  Google Scholar 

  • Takeda S, Rimington H, Smeeton N, Chambers J. Long axis excursion in aortic stenosis. Heart. 2001;86:52–6.

    Article  PubMed  CAS  Google Scholar 

  • Tongue AG, Dumesnil JG, Laforest I, Thériault C, Durand LG, Pibarot P. Left ventricular longitudinal shortening in patients with aortic stenosis: relationship with symptomatic status. J Heart Valve Dis. 2003;12:142–9.

    PubMed  Google Scholar 

  • Tribouilloy C, Levy F, Rusinaru D, et al. Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. J Am Coll Cardiol. 2009;53:1865–73.

    Article  PubMed  Google Scholar 

  • Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: the Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007;28:230–68.

    PubMed  Google Scholar 

  • Van Pelt NC, Stewart RA, Legget ME, et al. Longitudinal left ventricular contractile dysfunction after exercise in aortic stenosis. Heart. 2007;93:732–8.

    Article  PubMed  Google Scholar 

  • Vanderheyden M, Goethals M, Verstreken S. Wall stress modulates brain natriuretic peptide production in pressure overload cardiomyopathy. J Am Coll Cardiol. 2004;44:2349–54.

    Article  PubMed  CAS  Google Scholar 

  • Weber M, Hausen M, Arnold R, et al. Prognostic value of N-terminal pro-B-type natriuretic peptide for conservatively and surgically treated patients with aortic valve stenosis. Heart. 2006;92:1639–44.

    Article  PubMed  CAS  Google Scholar 

  • Weidemann F, Herrmann S, Stork S, et al. Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis. Circulation. 2009;120:577–84.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Medicine, Laval University, Quebec, QC, Canada

    Philippe Pibarot DVM, Ph.D. & Jean G. Dumesnil M.D., FRCP(C)

  2. Canadian Institutes of Health research, Ottawa, Canada

    Philippe Pibarot DVM, Ph.D.

Authors
  1. Philippe Pibarot DVM, Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jean G. Dumesnil M.D., FRCP(C)
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Philippe Pibarot DVM, Ph.D. .

Editor information

Editors and Affiliations

  1. , Molecular Biology and Biochemistry, Mayo Clinic, Rochester, 55905, Minnesota, USA

    Nalini M. Rajamannan

Rights and permissions

Reprints and permissions

Copyright information

© 2013 Springer-Verlag London

About this chapter

Cite this chapter

Pibarot, P., Dumesnil, J.G. (2013). Assessment of Aortic Stenosis Severity: Determining Timing to Surgery. In: Rajamannan, N. (eds) Cardiac Valvular Medicine. Springer, London. https://doi.org/10.1007/978-1-4471-4132-7_8

Download citation

  • DOI: https://doi.org/10.1007/978-1-4471-4132-7_8

  • Published:

  • Publisher Name: Springer, London

  • Print ISBN: 978-1-4471-4131-0

  • Online ISBN: 978-1-4471-4132-7

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation