open access

Vol 30, No 3 (2023)
Original Article
Submitted: 2021-06-04
Accepted: 2021-08-11
Published online: 2021-09-23
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Pseudo-discordance mimicking low-flow low-gradient aortic stenosis in transcatheter aortic valve replacement patients with severe symptomatic aortic stenosis

Rafael Kuperstein12, Michael Michlin12, Israel Barbash12, Israel Mazin12, Yafim Brodov123, Paul Fefer12, Amit Segev12, Victor Guetta12, Elad Maor12, Orly Goiten23, Michael Arad12, Micha S. Feinberg12, Ehud Schwammenthal12
·
Pubmed: 34581429
·
Cardiol J 2023;30(3):422-430.
Affiliations
  1. The Leviev Heart Center, Sheba Medical Center, Israel
  2. Sackler School of Medicine, Tel Aviv University, Israel
  3. Department of Diagnostic Imaging, Sheba Medical Center , Israel

open access

Vol 30, No 3 (2023)
Original articles — Clinical cardiology
Submitted: 2021-06-04
Accepted: 2021-08-11
Published online: 2021-09-23

Abstract

Background: While the combination of a small aortic valve area (AVA) and low mean gradient is
frequently labeled ‘low-flow low-gradient aortic stenosis (AS)’, there are two potential causes for this
finding: underestimation of mean gradient and underestimation of AVA.
Methods: In order to investigate the prevalence and causes of discordant echocardiographic findings in
symptomatic patients with AS and normal left ventricular (LV) function, we evaluated 72 symptomatic
patients with AS and normal LV function by comparing Doppler, invasive, computed tomography (CT)
LV outflow tract (LVOT) area, and calcium score (CaSc).
Results: Thirty-six patients had discordant echocardiographic findings (mean gradient < 40 mmHg,
AVA ≤ 1 cm2). Of those, 19 had discordant invasive measurements (true discordant [TD]) and 17 concordant
(false discordant [FD]): In 12 of the FD the mean gradient was > 30 mmHg; technical pitfalls
were found in 10 patients (no reliable right parasternal Doppler in 6). LVOT area by echocardiography
or CT could not differentiate between concordants and discordants nor between TD and FD (p = NS).
CaSc was similar in concordants and FD (p = 0.3), and it was higher in true concordants than in TD
(p = 0.005). CaSc positive predictive value for the correct diagnosis of severe AS was 95% for concordants
and 93% for discordants.
Conclusions: Discordant echocardiographic findings are commonly found in patients with symptomatic
AS. Underestimation of the true mean gradient due to technical difficulties is an important cause
of these discrepant findings. LVOT area by echocardiography or CT cannot differentiate between TD
and FD. In the absence of a reliable and compete multi-window Doppler evaluation, patients should
undergo CaSc assessment.

Abstract

Background: While the combination of a small aortic valve area (AVA) and low mean gradient is
frequently labeled ‘low-flow low-gradient aortic stenosis (AS)’, there are two potential causes for this
finding: underestimation of mean gradient and underestimation of AVA.
Methods: In order to investigate the prevalence and causes of discordant echocardiographic findings in
symptomatic patients with AS and normal left ventricular (LV) function, we evaluated 72 symptomatic
patients with AS and normal LV function by comparing Doppler, invasive, computed tomography (CT)
LV outflow tract (LVOT) area, and calcium score (CaSc).
Results: Thirty-six patients had discordant echocardiographic findings (mean gradient < 40 mmHg,
AVA ≤ 1 cm2). Of those, 19 had discordant invasive measurements (true discordant [TD]) and 17 concordant
(false discordant [FD]): In 12 of the FD the mean gradient was > 30 mmHg; technical pitfalls
were found in 10 patients (no reliable right parasternal Doppler in 6). LVOT area by echocardiography
or CT could not differentiate between concordants and discordants nor between TD and FD (p = NS).
CaSc was similar in concordants and FD (p = 0.3), and it was higher in true concordants than in TD
(p = 0.005). CaSc positive predictive value for the correct diagnosis of severe AS was 95% for concordants
and 93% for discordants.
Conclusions: Discordant echocardiographic findings are commonly found in patients with symptomatic
AS. Underestimation of the true mean gradient due to technical difficulties is an important cause
of these discrepant findings. LVOT area by echocardiography or CT cannot differentiate between TD
and FD. In the absence of a reliable and compete multi-window Doppler evaluation, patients should
undergo CaSc assessment.

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Keywords

aortic stenosis, echocardiography, aortic valve, valvular disease, calcium

About this article
Title

Pseudo-discordance mimicking low-flow low-gradient aortic stenosis in transcatheter aortic valve replacement patients with severe symptomatic aortic stenosis

Journal

Cardiology Journal

Issue

Vol 30, No 3 (2023)

Article type

Original Article

Pages

422-430

Published online

2021-09-23

Page views

2306

Article views/downloads

481

DOI

10.5603/CJ.a2021.0106

Pubmed

34581429

Bibliographic record

Cardiol J 2023;30(3):422-430.

Keywords

aortic stenosis
echocardiography
aortic valve
valvular disease
calcium

Authors

Rafael Kuperstein
Michael Michlin
Israel Barbash
Israel Mazin
Yafim Brodov
Paul Fefer
Amit Segev
Victor Guetta
Elad Maor
Orly Goiten
Michael Arad
Micha S. Feinberg
Ehud Schwammenthal

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