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Original article
Development of paradoxical low-flow, low-gradient severe aortic stenosis
  1. Jordi S Dahl1,
  2. Mackram F Eleid1,
  3. Sorin V Pislaru1,
  4. Christopher G Scott2,
  5. Heidi M Connolly1,
  6. Patricia A Pellikka1
  1. 1Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Division of Biostatistics Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Patricia A Pellikka, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester MN 55905, USA; pellikka.patricia{at}


Objective Among patients with severe aortic stenosis (sAS) and preserved LVEF, those with low-flow, low-gradient sAS (LFLG-sAS) have an adverse prognosis. It has been proposed that LFLG-sAS represents an end-stage point of sAS, but longitudinal information has not been described. The aim was to determine whether LFLG-sAS represents an end-stage consequence of normal-flow, high-gradient sAS (NFHG-sAS) or a different entity.

Methods From our transthoracic echocardiogram (TTE) database, we identified patients with sAS (aortic valve area <1 cm2) and preserved LVEF (≥50%), and from these, patients with LFLG-sAS (stroke volume index <35 mL/m2 and mean transvalvular gradient <40 mm Hg) who had ≥1 additional TTE within five years prior to the index TTE. Patients were age/sex/date matched 2:1 with patients with NFHG-sAS and normal-flow, low-gradient (NFLG)-sAS who also had ≥1 TTE. Included were 1203 TTEs (383 index studies and 820 preceding studies).

Results In 78 patients with LFLG-sAS, an HG stage preceded the index TTE in only 4 (5%). During the five years preceding the index TTE, patients with LFLG-sAS developed increasing relative wall thickness (0.42 to 0.49; p<0.001) without change in LV mass index. Patients with NFHG-sAS had a marked increase in LV mass index (87 to 115 g/m2; p<0.001). Patients with LFLG-sAS demonstrated the greatest reduction in LV end-diastolic diameters (−3 vs −1 for NFLG-sAS vs +2 mm for NFHG-sAS; p=0.001), deceleration time (−55 vs −3 vs +3 ms, respectively; p<0.01) and LVEF (−4 vs 0 vs 0%, respectively; p=0.01).

Conclusions LFLG-sAS is a distinct presentation of sAS preceded by a unique remodelling pathway and is uncommonly preceded by an HG stage.

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