Catheterization and Cardiovascular Diagnosis 43:201–205 (1998)

Hemodynamic Rounds

Hemodynamic Rounds Series II:

Low-Gradient Aortic Valve Stenosis
Morton J. Kern,* MD, and Sanjeev Puri, MD

INTRODUCTION CASE REPORT

The management of most patients with aortic stenosis Consider the findings in a 57-year-old man with
is generally straightforward. Patients with transvalvular increasing dyspnea and fatigue over the last 6 mo. Three
gradients $50 mm Hg, or a calculated aortic valve area of years ago he was noted to have mild aortic stenosis (30
#0.7 cm2, and who complain of angina, syncope, or mm Hg gradient, valve area .1.8 cm2) and moderately
symptoms of congestive heart failure, require surgery [1]. decreased left ventricular function (global hypokinesis,
Asymptomatic patients usually do not require surgery, ejection fraction of 48%). Coronary angiography showed
regardless of their hemodynamics [1–5]. An exceptional normal coronary arteries. Right-heart hemodynamics dem-
group consists of those symptomatic patients who have a onstrated increased right atrial pressure (12 mm Hg), and
small transvalvular gradient and a low cardiac output, mildly elevated right ventricular systolic and pulmonary
artery pressures (42/12 mm Hg and 42/28 mm Hg,
with a calculated aortic valve area of #0.7 cm2 [5]. In
respectively). Cardiac output by thermodilution was 3.1
these patients, substantial clinical doubt exists regarding
l/min. Examine the hemodynamics of the simultaneous
whether the aortic valve is sufficiently stenotic to account
femoral artery (previously matched to central aortic
for the symptoms, or whether the patient has only mild pressure before crossing the valve) and left ventricular
aortic valvular disease and the symptom complex is due pressures (Fig. 1, top). The rhythm is atrial fibrillation.
to a secondary cardiac problem (e.g., myopathic). The Aortic pressure varied between 144/70 mm Hg and
doubt regarding low-gradient aortic stenosis is justified, 120/80 mm Hg, with corresponding left ventricular
since the Gorlin formula is flow-dependent at a cardiac pressures between 165/35 mm Hg to 130/22 mm Hg.
output of ,4 l/min. The calculated valve area by the Peak-to-peak and mean aortic valve gradients fluctuated
Gorlin formula is extremely flow-dependent at flows ,3 from 25 mm Hg to 15 mm Hg. Valve resistance calcula-
l/min [6,7]. Because cardiac output at time of cardiac catheter- tions ranged from 200–175 units. What recommendation
ization greatly influences the clinical evaluation and subse- should be made?
quent management decisions, the use of valvular resistance Before making a decision, dobutamine (10 µg/kg/min
and recalculation of the aortic valve area after a pharmaco- for 3 min) was infused and hemodynamic data were
logic stimulation of cardiac output are often required to reexamined (Fig. 1, bottom, and Fig. 2). During dobuta-
facilitate the decision regarding surgery in these patients [8]. mine infusion, heart rate increased to 120 beats/min.
Aortic pressure averaged 118/65 mm Hg, left ventricular
pressure averaged 150/22 mm Hg, and cardiac output
AORTIC VALVE RESISTANCE
Aortic valve resistance is related to stenosis as follows: Division of Cardiology, Department of Internal Medicine, Saint
Valve resistance .300 dynes.sec.cm25 indicates severe Louis University Health Sciences Center, St. Louis, Missouri
disease, while resistance ,250 dynes.sec.cm25 indicates less
critical disease, with resistances of 250–300 dynes.sec.cm25 *Correspondence to: Morton J. Kern, M.D., Director, J.G. Mudd Cardiac
Catheterization Laboratory, Saint Louis University Health Sciences Center,
as intermediate. If a severe valvular stenosis exists, a pharma- 3635 Vista Avenue at Grand Blvd., St. Louis, MO 63110.
cologic challenge increasing cardiac output to .4.5 l/min
should not alter the valve area from the baseline value [9]. Received 20 August 1997; Accepted 20 August 1997

r 1998 Wiley-Liss, Inc.

202 Kern and Puri

Fig. 1. Aortic (Ao) pressure (femoral artery) and left ventricular (LV) pressure at baseline
(control, top) and after dobutamine 10 µg intravenous for 3 min (bottom). Scale, 0–200 mm Hg.

Fig. 2. Aortic (Ao) pressure (femoral artery), left ventricular (LV) pressure, and pulmonary
artery (PA) pressure at baseline (control, left) and after dobutamine 10 µg intravenous for 3 min
(right). Scale, 0–200 mm Hg.

increased to 4.2 l/min. Valve resistance was calculated at pulmonary artery (Fig. 2) and left ventricular end-
178 units. Figure 2 shows aortic, left ventricular, and diastolic pressures (Fig. 1, bottom). Based on these data
pulmonary artery pressures before (control) and after (Table I), a recommendation for continued medical
dobutamine infusion. Note the mild decline in systolic therapy without surgery was made.
 Low-Gradient Aortic Valve Stenosis 203

TABLE I. Hemodynamic Data

Heart Aortic Left ventricular Mean Cardiac Aortic valve Aortic
rate (bpm) pressure (mm Hg) pressure (mm Hg) gradient (mm Hg) output (l/min) area (cm2 ) valve resistance*
Baseline 85–100 120/80 135/30 18 3.1 1.0 200
Dobutamine 120 125/78 150/25 28 4.2 1.0 178
*dynes · sec · cm25

LOW OUTPUT AND VALVE AREAS ADDRESSING CONFLICTING DATA

Patients with relatively mild aortic-left ventricular In some patients, echocardiographic findings may be in
pressure gradients appear to have severe stenosis when conflict with the hemodynamic data. High systolic flow
valve area is calculated in the setting of low cardiac velocities in the aortic valve region may be due to either
output. However, when cardiac output is increased by valvular or subvalvular obstruction or, at times, may be
vasopressor infusions (e.g., dobutamine) or vasodilator confused with mitral regurgitation. In most patients with
agents (e.g., nitroprusside), a large increase in calculated suspected aortic stenosis suggested by transthoracic or
aortic valve area can be observed [10]. In some cases, transesophageal echo-Doppler, transvalvular pressure gra-
increased cardiac output physically produces a greater dients using simultaneous peripheral artery and left
valve orifice through improvement in leaflet mobility. ventricular pressures are usually confirmatory. However,
More commonly, increasing valve area is related to the in patients with aortic stenosis who have small or
flow dependence of the Gorlin formula [6]. moderate transvalvular gradients, a more accurate assess-
In severe valvular stenosis, increased cardiac output ment of pressure should be obtained with centrally placed
generally does not increase the calculated valve area, so catheters or transseptal technique. In clinical practice,
much that it falls outside the critical range .0.8 cm2. The micromanometer-tipped high-fidelity catheters are rarely
constant within the Gorlin formula appears to be variable used, but do provide the most precise pressure-gradient
at different flow rates. Historically, the Gorlin constant determinations. In patients with peripheral vascular dis-
was calculated only for the mitral valve where flow ease, hemodynamic data can be obtained with a single
dependence is less marked than with aortic stenosis. Flow arterial puncture using a long (90-cm) sheath to measure
dependence is not generally a problem in the midrange of pressures, and a pigtail catheter can be passed into the left
cardiac outputs between 4.0–5.0 l/min, or when the aortic ventricle for gradient measurements.
stenosis gradient exceeds 50 mm Hg. If improvement in Although the standard has been the transvalvular
the patient with low-gradient aortic stenosis can be gradient, Doppler echocardiography remains a highly
identified from vasodilator therapy during hemodynamic accurate test for hemodynamic assessment in patients
evaluation, chronic vasodilator therapy on an outpatient with aortic stenosis. Adele et al. [11] evaluated the
basis may be highly beneficial. significance of transvalvular catheter gradients in patients
with aortic stenosis, comparing them to Doppler echocar-
diographic determinations of the gradient in 18 patients.
KEY POINTS The peak instantaneous Doppler pressure gradient was
As noted by Carabello [10], higher with the catheter across the aortic valve compared
to that after withdrawal of the aortic catheter, and the
1. Severely stenotic aortic valve areas can be obtained mean pressure gradient was also higher before the
when both cardiac output and pressure gradient are catheter was withdrawn. The relation of change in
low. Doppler peak instantaneous pressure gradient to the
2. Maneuvers which increase cardiac output will almost initial peak instantaneous pressure gradient before cath-
always increase calculated valve area, except in truly eter pullback demonstrated good correspondence and a
severe aortic stenosis. In mild aortic valve disease, positive correlation slope, indicating that the catheter did
calculated valve area will increase, indicating that the contribute to an increased aortic gradient. Although the
stenosis is only mild and that surgery may not be cross-sectional area of an 8F catheter is 10% that of a
beneficial. valve area measuring 0.5 cm2, the effective area of a
3. Aortic valve resistance may be a useful adjunct to the catheter may be greater, depending on its orientation
Gorlin formula in assessing the severity of aortic across the narrowed valve orifice. The motion of the
stenosis. catheter may also create turbulence in transvalvular flow,
204 Kern and Puri

contributing to pressure loss in the poststenotic region. operative death and prosthetic valve-related complica-
Pliable valves may have an artificial increase in the valve tions is inherent in the procedure, the risk-benefit ratio is
orifice area with such a catheter. Discrepancies between not favorable to the asymptomatic patient.
measurements may be due to the catheter placed across The study of Otto et al. [13] reinforces the concept that
the aortic valve, contributing to an already diminished no single discrete valve area defining the critical valve
orifice area and leading to overestimation of the transval- exists, but that this area varies from patient to patient
vular gradient. Alternatively, the catheter may contribute depending on cardiac output and problems of the calcula-
to prying open one of the cusps, thereby increasing the tion of valve area. Patients may become symptomatic in
effective valve area, reducing the transvalvular gradient. the range of 0.6–0.8 cm2, whereas asymptomatic patients
This finding is in agreement with that of Carabello et may reside comfortably with valve areas of 0.8–1.0 cm2.
al. [12], where a .5-mm Hg increase in peripheral In general, patients with valve areas .1.0 cm2 are often
arterial pressure could be observed during left ventricular symptomatic due to other noncardiac sources, especially
catheter withdrawal in patients with severe aortic steno- if the mean transvalvular gradient is ,30 mm Hg.
sis, postulated to be due to catheter cross-sectional area.
In most patients, the presence of a catheter across the
stenotic aortic valve does result in a significant increase in CONCLUSIONS
measured transvalvular pressure gradients, and the cath-
eter effect is proportional to the severity of the underlying Before accepting hemodynamic data indicating the
aortic stenosis. Systematic over- or underestimation of critical severity of aortic stenosis in individuals with left
the actual transvalvular gradient should always be consid- ventricular dysfunction and low cardiac output, evalua-
ered. tion of valve function with inotropic agents or vasodila-
tors [6] and their effect on aortic valve area and resistance
should be considered.
ASYMPTOMATIC AORTIC STENOSIS
Otto et al. [13] examined the prospective outcomes of
patients with valvular aortic stenosis who were asymptom- ACKNOWLEDGMENTS
atic. One hundred twenty-three patients with asymptom- The author thanks the J.G. Mudd Cardiac Catheteriza-
atic aortic stenosis were followed on an annual basis for tion Laboratory Team for technical support, and Donna
2.5 6 1.4 yr. Doppler aortic jet velocity increased by Sander for manuscript preparation.
0.32 6 0.34 m/sec/yr, with a mean gradient increase of
7 6 7 mm Hg/yr and a valve area decrease of 0.12 6 0.19
cm2/yr. At 3-yr follow-up, survival was 62 6 8%, and REFERENCES
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