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• Paradoxical low-flow low-gradient aortic stenosis: advanced severe disease, a new entity or a progression of disease?
  Calvin WL Chin
  Published on: 23 November 2015

• Published on: 23 November 2015

  Paradoxical low-flow low-gradient aortic stenosis: advanced severe disease, a new entity or a progression of disease?

  • Calvin WL Chin, Consultant

  I read the research by Dahl et al. with great interest (1). The authors have suggested paradoxical low-flow low-gradient aortic stenosis is a distinct entity, and not an advanced stage of severe aortic stenosis. Indeed, they have observed only 5% of these patients had high-gradient severe disease prior to the index assessment (1).

  Recent studies have demonstrated that paradoxical low-flow low- gradient is a hete...

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  I read the research by Dahl et al. with great interest (1). The authors have suggested paradoxical low-flow low-gradient aortic stenosis is a distinct entity, and not an advanced stage of severe aortic stenosis. Indeed, they have observed only 5% of these patients had high-gradient severe disease prior to the index assessment (1).

  Recent studies have demonstrated that paradoxical low-flow low- gradient is a heterogeneous subgroup of patients with aortic valve calcification (based on computed tomography), echocardiographic and cardiovascular magnetic resonance features between those observed in concordant non-severe and severe disease (2-4). Moreover, more than 80% of patients with paradoxical low-flow low-gradient severe aortic stenosis experienced progression of aortic stenosis severity, with half of them to high-gradient severe disease (5). Instead of an advanced stage of severe disease or a distinct entity, these studies have suggested paradoxical low -flow low-gradient severe aortic stenosis is a stage in transition from non-severe to severe disease.

  Consistent with this hypothesis, all the patients in the current study have progressed from non-severe disease, albeit at different rates and with different remodelling patterns (Figures 1, 2 and 3 (1)). In this regard, paradoxical low-flow low-gradient severe aortic stenosis (and for that matter, the other flow and gradient patterns) reflects the complex interaction between aortic valve calcification and heterogeneous hypertrophic response, rather than a new entity.

  Longitudinal studies with multi-modality imaging approaches (echocardiography, computed tomography and cardiovascular magnetic resonance) will be essential to fully examine this complex interaction between the valve and the myocardium; and to identify unique characteristics that determine progression in the different flow-gradient patterns.

  References 1. Dahl JS, Eleid MF, Pislaru SV, Scott CG, Connolly HM, Pellikka PA. Development of paradoxical low-flow, low-gradient severe aortic stenosis. Heart. 2015 Mar 20 [Epub ahead of pring]. 2. Chin C, Khaw J, Luo E, Tan SW, White A, Newby DE, et al. Echocardiography Underestimates Stroke Volume and Aortic Valve Area: Implications for Patients With Small-Area Low-Gradient Aortic Stenosis. Can J Cardiol. 2014;30(9):1064-72. 3. Barone-Rochette G, Pi?rard S, Seldrum S, de Meester de Ravenstein C, Melchior J, Maes F, et al. Aortic Valve Area, Stroke Volume, Left Ventricular Hypertrophy, Remodeling, and Fibrosis in Aortic Stenosis Assessed by Cardiac Magnetic Resonance Imaging: Comparison Between High and Low Gradient and Normal and Low Flow Aortic Stenosis. Circ Cardiovasc Imaging. 2013;6(6):1009-17. 4. Clavel M-A, Messika-Zeitoun D, Pibarot P, Aggarwal S, Malouf JF, Araoz P, et al. The complex nature of discordant severe calcified aortic valve disease grading. J Am Coll Cardiol. 2013;62(24):2329-38. 5. Maes F, Boulif J, Pi?rard S, de Meester C, Melchior J, Gerber B, et al. Natural History of Paradoxical Low-Gradient Severe Aortic Stenosis. Circ Cardiovasc Imaging. 2014;7(4):714-22.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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