Actualización en válvula aórtica bicúspide y complicaciones asociadas

Bicuspid aortic valve (BAV) is the most common congenital heart disease affecting 1-2% of the population. It affects more frequently males than females with a ratio of 3:1. Despite the fact that it has been historically considered a relatively benign disease, 35% of individuals with BAV will develop complications throughout life such as valve dysfunction, aortic aneurysm or aortic dissection. In spite of the relevance of this disease many aspects are not still clarified. The aim of this article is to show an updated version of the basic aspects of this pathology with emphasis on the latest developments related to the diagnosis, evolution and associated complications from a cardiac imaging viewpoint.La válvula aórtica bicúspide (VAB) es la cardiopatía congénita más frecuente y afecta a un 1-2% de la población. Afecta de forma más habitual a varones que a mujeres, con una relación 3:1. A pesar de haberse considerado históricamente una patología de carácter relativamente benigno, un 35% de los individuos con VAB desarrollará a lo largo de la vida complicaciones derivadas como disfunción valvular, endocarditis, aneurisma aórtico o disección aórtica. A pesar de la relevancia de esta patología quedan aún muchos aspectos por dilucidar. El objetivo de este artículo es mostrar una revisión actualizada de los aspectos básicos de esta patología haciendo hincapié en las últimas novedades relacionadas con su diagnóstico, evolución y complicaciones asociadas desde el punto de vista de la imagen cardíaca

Comparación de los resultados a largo plazo de cirugía y valvuloplastia percutánea para el tratamiento de la estenosis pulmonar aislada

Se compararon en una población de 211 pacientes con estenosis pulmonar reparada el tratamiento quirúrgico y percutáneo, las complicaciones y reintervenciones a largo plazo y predictores de las mismas. Los pacientes del grupo quirúrgico se intervinieron de forma más precoz, presentaban una anatomía más compleja, más síntomas y peor perfil hemodinámico. El tiempo medio de seguimiento global fue de 22 ± 10,21 años y no se observaron diferencias significativas en cuanto a la necesidad de reintervención. La aparición de complicaciones no difirió entre los dos grupos. Una mayor edad en el momento de la cirugía, defectos congénitos asociados y síntomas prequirúrgicos fueron factores de riesgo para padecer complicaciones mayores. Por lo tanto, a pesar de que la evolución a largo plazo es globalmente buena, la aparición de complicaciones y la necesidad de reintervención a lo largo del seguimiento no es despreciable y sigue reportándose a pesar de la introducción de la valvuloplastia percutánea como tratamiento de primera línea.Es van comparar en una població de 211 pacients amb estenosi pulmonar reparada el tractament quirúrgic i percutani, les complicacions i reintervencions a llarg termini i predictors d'aquestes. Els pacients del grup quirúrgic es van reintervenir de forma més precoç, presentaven una anatomia més complexa, més símptomes i pitjor perfil hemodinàmic. El temps mig de seguiment global va ser de 22 ± 10,21 anys i no es van observar diferències significatives pel que fa a la la necesitat de reintervenció. L'aparició de complicacions no va diferir entre els dos grups. Més edat en el moment de la cirurgia, presentar defectes congènits associats i símptomes prequirúrgics van ser factors de risc per patir complicacions majors. Per tant, tot i que l'evolució a llarg termini és globalment bona, l'aparició de complicacions i la necesitat de reintervenció al llarg del seguiment no és despreciable i segueix reportant-se malgrat la introducció de la valvuloplàstia percutània com a tractament de primera linia

Diagnostic value of quantitative parameters for myocardial perfusion assessment in patients with suspected coronary artery disease by single- and dual-energy computed tomography myocardial perfusion imaging

To compare performance of visual and quantitative analyses for detecting myocardial ischaemia from single- and dual-energy computed tomography (CT) in patients with suspected coronary artery disease (CAD). Eighty-four patients with suspected CAD were scheduled for dual-energy cardiac CT at rest (CTA) and pharmacological stress (CTP). Myocardial CT perfusion was analysed visually and using three parameters: mean attenuation density (MA), transmural perfusion ratio (TPR) and myocardial perfusion reserve index (MPRI), on both single-energy CT and CT-based iodine images. Significant CAD was defined in AHA-segments by concomitant myocardial hypoperfusion identified visually or quantitatively (parameter < threshold) and coronary stenosis detected by CTA. Single-photon emission CT and invasive coronary angiography were used as reference. Perfusion-parameter cut-off values were calculated in a randomly-selected subgroup of 30 patients. The best-performing thresholds for TPR, MPRI and MA were 0.96, 23 and 0.5 for single-energy CT and 0.97, 47 and 0.3 for iodine imaging. For both CT-imaging modalities, TPR yielded the highest area under receiver operating characteristic curve (AUC) (0.99 and 0.97 for single-energy CT and iodine imaging, respectively, in vessel-based analysis) compared to visual analysis, MA and MPRI. Visual interpretation on iodine imaging resulted in higher AUC compared to that on single-energy CT in per-vessel (AUC: 0.93 vs 0.86, respectively) and per-patient (0.94 vs 0.93) analyses. Transmural perfusion ratio on both CT-imaging modalities is the best-performing parameter for detecting myocardial ischaemia compared to visual method and other perfusion parameters. Visual analysis on CT-based iodine imaging outperforms that on single-energy CT

Decreased rotational flow and circumferential wall shear stress as early markers of descending aorta dilation in Marfan syndrome : a 4D flow CMR study

Diseases of the descending aorta have emerged as a clinical issue in Marfan syndrome following improvements in proximal aorta surgical treatment and the consequent increase in life expectancy. Although a role for hemodynamic alterations in the etiology of descending aorta disease in Marfan patients has been suggested, whether flow characteristics may be useful as early markers remains to be determined. Seventy-five Marfan patients and 48 healthy subjects were prospectively enrolled. In- and through-plane vortexes were computed by 4D flow cardiovascular magnetic resonance (CMR) in the thoracic aorta through the quantification of in-plane rotational flow and systolic flow reversal ratio, respectively. Regional pulse wave velocity and axial and circumferential wall shear stress maps were also computed. In-plane rotational flow and circumferential wall shear stress were reduced in Marfan patients in the distal ascending aorta and in proximal descending aorta, even in the 20 patients free of aortic dilation. Multivariate analysis showed reduced in-plane rotational flow to be independently related to descending aorta pulse wave velocity. Conversely, systolic flow reversal ratio and axial wall shear stress were altered in unselected Marfan patients but not in the subgroup without dilation. In multivariate regression analysis proximal descending aorta axial (p = 0.014) and circumferential (p = 0.034) wall shear stress were independently related to local diameter. Reduced rotational flow is present in the aorta of Marfan patients even in the absence of dilation, is related to aortic stiffness and drives abnormal circumferential wall shear stress. Axial and circumferential wall shear stress are independently related to proximal descending aorta dilation beyond clinical factors. In-plane rotational flow and circumferential wall shear stress may be considered as an early marker of descending aorta dilation in Marfan patients. The online version of this article (10.1186/s12968-019-0572-1) contains supplementary material, which is available to authorized users

Aortic flow patterns and wall shear stress maps by 4D-flow cardiovascular magnetic resonance in the assessment of aortic dilatation in bicuspid aortic valve disease

Altres ajuts: This study has been funded by , La Marató de TV3 (project number 20151330). Guala A. has received funding from the European Union Seventh Framework Programme FP7/People under grant agreement n° 267128.In patients with bicuspid valve (BAV), ascending aorta (AAo) dilatation may be caused by altered flow patterns and wall shear stress (WSS). These differences may explain different aortic dilatation morphotypes. Using 4D-flow cardiovascular magnetic resonance (CMR), we aimed to analyze differences in flow patterns and regional axial and circumferential WSS maps between BAV phenotypes and their correlation with ascending aorta dilatation morphotype. One hundred and one BAV patients (aortic diameter ≤ 45 mm, no severe valvular disease) and 20 healthy subjects were studied by 4D-flow CMR. Peak velocity, flow jet angle, flow displacement, in-plane rotational flow (IRF) and systolic flow reversal ratio (SFRR) were assessed at different levels of the AAo. Peak-systolic axial and circumferential regional WSS maps were also estimated. Unadjusted and multivariable adjusted linear regression analyses were used to identify independent correlates of aortic root or ascending dilatation. Age, sex, valve morphotype, body surface area, flow derived variables and WSS components were included in the multivariable models. The AAo was non-dilated in 24 BAV patients and dilated in 77 (root morphotype in 11 and ascending in 66). BAV phenotype was right-left (RL-) in 78 patients and right-non-coronary (RN-) in 23. Both BAV phenotypes presented different outflow jet direction and velocity profiles that matched the location of maximum systolic axial WSS. RL-BAV velocity profiles and maximum axial WSS were homogeneously distributed right-anteriorly, however, RN-BAV showed higher variable profiles with a main proximal-posterior distribution shifting anteriorly at mid-distal AAo. Compared to controls, BAV patients presented similar WSS magnitude at proximal, mid and distal AAo (p = 0.764, 0.516 and 0.053, respectively) but lower axial and higher circumferential WSS components (p < 0.001 for both, at all aortic levels). Among BAV patients, RN-BAV presented higher IRF at all levels (p = 0.024 proximal, 0.046 mid and 0.002 distal AAo) and higher circumferential WSS at mid and distal AAo (p = 0.038 and 0.046, respectively) than RL-BAV. However, axial WSS was higher in RL-BAV compared to RN-BAV at proximal and mid AAo (p = 0.046, 0.019, respectively). Displacement and axial WSS were independently associated with the root-morphotype, and circumferential WSS and SFRR with the ascending-morphotype. Different BAV-phenotypes present different flow patterns with an anterior distribution in RL-BAV, whereas, RN-BAV patients present a predominant posterior outflow jet at the sinotubular junction that shifts to anterior or right anterior in mid and distal AAo. Thus, RL-BAV patients present a higher axial WSS at the aortic root while RN-BAV present a higher circumferential WSS in mid and distal AAo. These results may explain different AAo dilatation morphotypes in the BAV population. The online version of this article (10.1186/s12968-018-0451-1) contains supplementary material, which is available to authorized users

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume–pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference

Comparación de los resultados a largo plazo de cirugía y valvuloplastia percutánea para el tratamiento de la estenosis pulmonar aislada.

Se compararon en una población de 211 pacientes con estenosis pulmonar reparada el tratamiento quirúrgico y percutáneo, las complicaciones y reintervenciones a largo plazo y predictores de las mismas. Los pacientes del grupo quirúrgico se intervinieron de forma más precoz, presentaban una anatomía más compleja, más síntomas y peor perfil hemodinámico. El tiempo medio de seguimiento global fue de 22 ± 10,21 años y no se observaron diferencias significativas en cuanto a la necesidad de reintervención. La aparición de complicaciones no difirió entre los dos grupos. Una mayor edad en el momento de la cirugía, defectos congénitos asociados y síntomas prequirúrgicos fueron factores de riesgo para padecer complicaciones mayores. Por lo tanto, a pesar de que la evolución a largo plazo es globalmente buena, la aparición de complicaciones y la necesidad de reintervención a lo largo del seguimiento no es despreciable y sigue reportándose a pesar de la introducción de la valvuloplastia percutánea como tratamiento de primera línea.Es van comparar en una població de 211 pacients amb estenosi pulmonar reparada el tractament quirúrgic i percutani, les complicacions i reintervencions a llarg termini i predictors d’aquestes. Els pacients del grup quirúrgic es van reintervenir de forma més precoç, presentaven una anatomia més complexa, més símptomes i pitjor perfil hemodinàmic. El temps mig de seguiment global va ser de 22 ± 10,21 anys i no es van observar diferències significatives pel que fa a la la necesitat de reintervenció. L’aparició de complicacions no va diferir entre els dos grups. Més edat en el moment de la cirurgia, presentar defectes congènits associats i símptomes prequirúrgics van ser factors de risc per patir complicacions majors. Per tant, tot i que l’evolució a llarg termini és globalment bona, l’aparició de complicacions i la necesitat de reintervenció al llarg del seguiment no és despreciable i segueix reportant-se malgrat la introducció de la valvuloplàstia percutània com a tractament de primera linia

Estenosis aórtica severa de bajo flujo y bajo gradiente con fracción de eyección normal : Prevalencia, características, pronóstico e historia natural

Introducció: L'estenosi aòrtica (EAo) de baix flux i baix gradient (BF/BG) amb fracció d'ejecció del ventricle esquerre (FEVE) normal és una entitat que s'ha associat amb un pitjor pronòstic que l'EAo d'elevat gradient (EG); tot i això, diferents estudis i recents meta-anàlisis posen en dubte els resultats previs. Objectiu: Determinar el risc de mortalitat i/o necessitat de cirurgia/TAVI en els pacients amb EAo severa amb BF/BG i FEVE conservada en comparació amb l'EAo severa amb flux normal i baix gradient (NF/BG) i amb EG. Materials i mètodes: Estudi observacional longitudinal retrospectiu de pacients diagnosticats entre 2008 i 2016 d'EAo severa (AVA 35 ml/m² i gradient mig 35 ml/m² y gradiente medio 35 ml/m² and mean gradient <40 mmHg) and LF/LG (SVi ≤ 35 ml / m² and mean gradient <40 mmHg). Baseline and long-term clinical, demographic and echocardiographic variables were collected. Results: A total of 1,391 patients were included and classified as: 147 (10.5%) LF/LG, 752 (54 0.1%) HG and 492 (35.4%) NF/LG. Throughout follow-up (59.0 months; IQR 39.7 - 82.9 months), 899 patients (64.6%) received aortic valve replacement or TAVI, 551 with HG (73.3%; median time: 12.3 months, IQR 3.5-32.6), 81 with LF/LG AS (55.1%; median time: 28.7 months, IQR 6.8-44.6), and 267 with NF/LG (54.3%; median time: 29.9 months, IQR: 14,1-49,4), with HG AS patients requiring surgery/TAVI earlier than NF/LG (Log-Rank p <0.001) and LF/LG AS patients (p <0.001), without significant differences between the LF/LG and NF/LG (p=0.358). During follow-up, 385 patients died (overall mortality 27.7%): 46 in LF/LG group (31.3%; median time: 50.8 months, IQR: 29.6-75.8), 205 in HG group (27.3%; median time: 56.1 months, IQR: 33.8-83.7) and 134 in NF/LG group (27.2%; median time: 53.19 months, IQR: 31.0 -76.9) with no significant differences among groups (p=0.319). It was observed that the benefit of surgery (in terms of overall mortality risk reduction) in the whole AS population was significant, with HG AS patients benefiting the most (HR: 0.17; 95% CI: 0.12-0.23; p <0.001) followed by LF/LG patients (HR: 0.25; 95% CI: 0.13-0.49; p <0.001) and finally NF/LG (HR: 0.29, 95% CI: 0.20-0.44; p <0.001). Progression of the mean gradient throughout follow-up was greater in low gradient groups: LF/LG and NF/LG compared to HG (LF/LG vs. HG: p=0.022; NF/LG vs. HG: p=0.013) with no significant differences between LF/LG and NF/LG (p=0.426) and considering AVA progression, no significant differences were observed between the LF/LG and HG groups (p=0.452), with this decrease being greater in the NF/LG group than in others (NF/LG vs. HG: p = 0.007; NF/LG vs. LF/LG: p = 0.013). LVEF progression did not differ significantly among groups (LF/LG vs. HG: p = 0.353; NF/LG vs. HG: p = 0.626, LF/LG vs. NF/LG: p = 0.212). Conclusions: Paradoxical LF/LG AS is a rare entity that affects 10.5% of the population. The need for surgery/TAVI in the LF/LG group was lower than in the HG group and similar to NF/LG group, without significant differences in overall and cardiovascular mortality. All patients with significant AS benefited from aortic valve surgery in terms of overall mortality reduction, which was less beneficial in LF/LG AS compared to HG AS. Study of AVA and mean gradient progression revealed an intermediate pattern of LF/LG between the HG and NF/LG groups. Therefore, the findings of the present study conclude that LF/LG has an intermediate clinical profile between the HG and NF/HG groups

Estenosis aórtica severa de bajo flujo y bajo gradiente con fracción de eyección normal: Prevalencia, características, pronóstico e historia natural

Introducció: L’estenosi aòrtica (EAo) de baix flux i baix gradient (BF/BG) amb fracció d’ejecció del ventricle esquerre (FEVE) normal és una entitat que s’ha associat amb un pitjor pronòstic que l’EAo d’elevat gradient (EG); tot i això, diferents estudis i recents meta-anàlisis posen en dubte els resultats previs. Objectiu: Determinar el risc de mortalitat i/o necessitat de cirurgia/TAVI en els pacients amb EAo severa amb BF/BG i FEVE conservada en comparació amb l’EAo severa amb flux normal i baix gradient (NF/BG) i amb EG. Materials i mètodes: Estudi observacional longitudinal retrospectiu de pacients diagnosticats entre 2008 i 2016 d’EAo severa (AVA 35 ml/m² i gradient mig < 40 mmHg) i BF/BG (VEi ≤ 35 ml/m² i gradient mig < 40 mmHg). Es recolliren variables clíniques, demogràfiques i ecocardiogràfiques basals i a llarg termini. Resultats: S’inclogueren 1391 pacients: 147 (10,5%) BF/BG, 752 (54,1%) EG i 492 (35,4%) NF/BG. Al llarg del seguiment (59,0 mesos; RIC 39,7 - 82,9), 899 pacients (64,6%) van rebre substitució valvular aòrtica o TAVI, 551 amb EG (73,3%; mediana temps: 12,3 mesos, RIC 3,5-32,6), 81 pacients amb EAo BF/BG (55,1%; mediana temps: 28,7 mesos, RIC 6,8-44,6), i 267 amb NF/BG (54,3%; mediana temps: 29,9 mesos, RIC: 14,1-49,4) objectivant que la EAo EG va requerir cirurgia/TAVI de forma més precoç que la EAo NF/BG (p<0,001) i que la EAo BF/BG (p<0,001), sense diferències entre la EAo BF/BG i la EAo NF/BG (p=0,358). Durant el seguiment es registraren 385 morts (mortalitat global del 27,7%): 46 del grup BF/BG (31,3%; mediana de temps: 50,8 mesos, RIC: 29,6-75,8), 205 del grup EG (27,3%; mediana de temps: 56,1 mesos, RIC: 33,8-83,7) i 134 del grup NF/BG (27,2%; mediana de temps: 53,19 mesos, RIC: 31,0-76,9) sense observar-se diferencies significatives entre els 3 grups (p=0,319). Així mateix, s’observà que el benefici de la cirurgia/TAVI en termes de reducció de mortalitat global en tota la població amb EAo fou important, essent els pacients amb EAo EG els que més es beneficiaren (HR: 0,17; IC 95%: 0,12-0,23; p < 0,001), seguits dels pacients BF/BG (HR: 0,25; IC 95%: 0,13-0,49; p < 0,001) i en darrer lloc els NF/BG (HR: 0,29; IC 95%: 0,20-0,44; p < 0,001). S’observà que la progressió del gradient mig al llarg del seguiment fou major en els grups amb baix gradient en comparació amb el grup EG (BF/BG vs. EG: p=0,022; NF/BG vs. EG: p=0,013) i respecte a l’AVA no s’observaren diferències significatives entre el grup BF/BG i el grup EG (p=0,452), essent major la disminució en el grup NF/BG que en el grup EG i BF/BG (NF/BG vs. EG: p=0,007; NF/BG vs. BF/BG: p=0,013). Conclusions: L’EAo BF/BG és una entitat poc freqüent que afecta el 10,5% de la població. La indicació de cirurgia/TAVI en el grup BF/BG fou menor que en el grup EG i similar al grup NF/BG, sense diferències significatives en la mortalitat. El benefici de la cirurgia en relació a la reducció de la mortalitat global fou menor en els pacients amb EAo BF/BG en comparació amb els pacients EG. L’estudi de l’evolució de l’AVA i el gradient mig del grup BF/BG va mostrar un patró intermedi entre el grup EG i NF/BG. Les troballes del present estudi ens fan concloure que la EAo BF/BG té un comportament clínic intermedi entre els grups EG i NF/BG.Introducción: La estenosis aórtica (EAo) de bajo flujo y bajo gradiente (BF/BG) con fracción de eyección del ventrículo izquierdo (FEVI) normal es una entidad que se ha asociado con un peor pronóstico que la EAo de elevado gradiente (EG); a pesar de ello, distintos estudios y recientes meta-análisis ponen en duda los resultados previos. Objetivo: Determinar el riesgo de mortalidad y/o necesidad de cirugía/TAVI en los pacientes con EAo severa con BF/BG y FEVI conservada en comparación con la EAo severa con flujo normal con bajo gradiente (NF/BG) y con EG. Materiales y métodos: Estudio observacional longitudinal retrospectivo de pacientes diagnosticados entre 2008 y 2016 de EAo severa (AVA 35 ml/m² y gradiente medio < 40 mmHg y) y BF/BG (VEi ≤ 35 ml/m² y gradiente medio < 40 mmHg). Se recogieron variables clínicas, demográficas y ecocardiográficas basales y a largo plazo. Resultados: Se incluyeron 1391 pacientes: 147 (10,5%) BF/BG, 752 (54,1%) EG y 492 (35,4%) NF/BG. A lo largo del seguimiento (59,0 meses; RIC 39,7 - 82,9), 899 pacientes (64,6%) recibieron remplazo valvular aórtico o TAVI, 551 con EG (73,3%; mediana tiempo: 12,3 meses, RIC 3,5-32,6), 81 pacientes con EAo BF/BG (55,1%; mediana tiempo: 28,7 meses, RIC 6,8-44,6), y 267 con NF/BG (54,3%; mediana tiempo: 29,9 meses, RIC: 14,1-49,4) objetivando que la EAo EG requirió cirugía/TAVI de forma más precoz que la EAo NF/BG (p<0,001) y que la EAo BF/BG (p<0,001), sin diferencias entre la EAo BF/BG y la EAo NF/BG (p=0,358). Durante el seguimiento se registraron 385 fallecimientos (mortalidad global del 27,7%): 46 del grupo BF/BG (31,3%; mediana de tiempo: 50,8 meses, RIC: 29,6-75,8), 205 del grupo EG (27,3%; mediana de tiempo: 56,1 meses, RIC: 33,8-83,7) y 134 del grupo NF/BG (27,2%; mediana de tiempo: 53,19 meses, RIC: 31,0-76,9) sin observarse diferencias significativas entre los 3 grupos (p=0,319). Asimismo, se observó que el beneficio de la cirugía/TAVI en términos de reducción de mortalidad global en toda la población con EAo fue importante, siendo los pacientes con EAo EG los que más se beneficiaron (HR: 0,17; IC 95%: 0,12-0,23; p < 0,001), seguidos de los pacientes BF/BG (HR: 0,25; IC 95%: 0,13-0,49; p < 0,001) y en último lugar los NF/BG (HR: 0,29; IC 95%: 0,20-0,44; p < 0,001). Se observó que la progresión del gradiente medio a lo largo del seguimiento fue mayor en los grupos con bajo gradiente en comparación con el grupo EG (BF/BG vs. EG: p=0,022; NF/BG vs. EG: p=0,013) y respecto al AVA no se observaron diferencias significativas entre el grupo BF/BG y el grupo EG (p=0,452), siendo mayor la disminución en el grupo NF/BG que en el grupo EG y BF/BG (NF/BG vs. EG: p=0,007; NF/BG vs. BF/BG: p=0,013). Conclusiones: La EAo BF/BG es una entidad poco frecuente que afecta al 10,5% de la población. La indicación de cirugía/TAVI en el grupo BF/BG fue menor que en el grupo EG y similar al grupo NF/BG, sin diferencias significativas en la mortalidad. El beneficio de la cirugía en relación a la reducción de la mortalidad global fue menor en los pacientes con EAo BF/BG en comparación con los pacientes EAo EG. El estudio de la evolución del AVA y el gradiente medio del grupo BF/BG mostró un patrón intermedio entre el grupo EG y NF/BG. Los hallazgos del presente estudio nos hacen concluir que la EAo BF/BG tiene un comportamiento clínico intermedio entre los grupos EG y NF/BG.Introduction: Severe paradoxical low-flow/low-gradient (LF/LG) aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) has been associated with worse prognosis than high gradient (HG) AS. However, different studies and recent meta-analyses question the previous results. Aim: To determine the mortality risk and the need for surgery in patients with severe LF/LG AS and preserved LVEF compared to severe AS with normal flow and high (HG) and low gradient (NF/LG). Materials and methods: A retrospective longitudinal observational study of patients diagnosed of severe AS (AVA 35 ml/m² and mean gradient <40 mmHg) and LF/LG (SVi ≤ 35 ml / m² and mean gradient <40 mmHg). Baseline and long-term clinical, demographic and echocardiographic variables were collected. Results: A total of 1,391 patients were included and classified as: 147 (10.5%) LF/LG, 752 (54 0.1%) HG and 492 (35.4%) NF/LG. Throughout follow-up (59.0 months; IQR 39.7 - 82.9 months), 899 patients (64.6%) received aortic valve replacement or TAVI, 551 with HG (73.3%; median time: 12.3 months, IQR 3.5-32.6), 81 with LF/LG AS (55.1%; median time: 28.7 months, IQR 6.8-44.6), and 267 with NF/LG (54.3%; median time: 29.9 months, IQR: 14,1-49,4), with HG AS patients requiring surgery/TAVI earlier than NF/LG (Log-Rank p <0.001) and LF/LG AS patients (p <0.001), without significant differences between the LF/LG and NF/LG (p=0.358). During follow-up, 385 patients died (overall mortality 27.7%): 46 in LF/LG group (31.3%; median time: 50.8 months, IQR: 29.6-75.8), 205 in HG group (27.3%; median time: 56.1 months, IQR: 33.8-83.7) and 134 in NF/LG group (27.2%; median time: 53.19 months, IQR: 31.0 -76.9) with no significant differences among groups (p=0.319). It was observed that the benefit of surgery (in terms of overall mortality risk reduction) in the whole AS population was significant, with HG AS patients benefiting the most (HR: 0.17; 95% CI: 0.12-0.23; p <0.001) followed by LF/LG patients (HR: 0.25; 95% CI: 0.13-0.49; p <0.001) and finally NF/LG (HR: 0.29, 95% CI: 0.20-0.44; p <0.001). Progression of the mean gradient throughout follow-up was greater in low gradient groups: LF/LG and NF/LG compared to HG (LF/LG vs. HG: p=0.022; NF/LG vs. HG: p=0.013) with no significant differences between LF/LG and NF/LG (p=0.426) and considering AVA progression, no significant differences were observed between the LF/LG and HG groups (p=0.452), with this decrease being greater in the NF/LG group than in others (NF/LG vs. HG: p = 0.007; NF/LG vs. LF/LG: p = 0.013). LVEF progression did not differ significantly among groups (LF/LG vs. HG: p = 0.353; NF/LG vs. HG: p = 0.626, LF/LG vs. NF/LG: p = 0.212). Conclusions: Paradoxical LF/LG AS is a rare entity that affects 10.5% of the population. The need for surgery/TAVI in the LF/LG group was lower than in the HG group and similar to NF/LG group, without significant differences in overall and cardiovascular mortality. All patients with significant AS benefited from aortic valve surgery in terms of overall mortality reduction, which was less beneficial in LF/LG AS compared to HG AS. Study of AVA and mean gradient progression revealed an intermediate pattern of LF/LG between the HG and NF/LG groups. Therefore, the findings of the present study conclude that LF/LG has an intermediate clinical profile between the HG and NF/HG groups.Universitat Autònoma de Barcelona. Programa de Doctorat en Medicin

Prognosis of paradoxical low-flow low-gradient aortic stenosis: a severe, non-critical form, with surgical treatment benefits

Objectives: to determine the risk of mortality and need for aortic valve replacement (AVR) in patients with low-flow low-gradient (LFLG) aortic stenosis (AS). Methods: a longitudinal multicentre study including consecutive patients with severe AS (aortic valve area [AVA] 35 ml/m2) and LFLG (mean gradient < 40 mmHg, SVi ≤ 35 ml/m2). Results: of 1,391 patients, 147 (10.5%) had LFLG, 752 (54.1%) HG, and 492 (35.4%) NFLG. Echocardiographic parameters of the LFLG group showed similar AVA to the HG group but with less severity in the dimensionless index, calcification, and hypertrophy. The HG group required AVR earlier than NFLG (p < 0.001) and LFLG (p < 0.001), with no differences between LFLG and NFLG groups (p = 0.358). Overall mortality was 27.7% (CI 95% 25.3-30.1) with no differences among groups (p = 0.319). The impact of AVR in terms of overall mortality reduction was observed the most in patients with HG (hazard ratio [HR]: 0.17; 95% CI: 0.12-0.23; p < 0.001), followed by patients with LFLG (HR: 0.25; 95% CI: 0.13-0.49; p < 0.001), and finally patients with NFLG (HR: 0.29; 95% CI: 0.20-0.44; p < 0.001), with a risk reduction of 84, 75, and 71%, respectively. Conclusions: paradoxical LFLG AS affects 10.5% of severe AS, and has a lower need for AVR than the HG group and similar to the NFLG group, with no differences in mortality. AVR had a lower impact on LFLG AS compared with HG AS. Therefore, the findings of the present study showed LFLG AS to have an intermediate clinical risk profile between the HG and NFHG groups.AGu has received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018- 037349-I)