Low-Gradient,Low Ejection Fraction Severe Aortic Stenosis:Still a Management Conundrum

The management of patients with severe symptomatic aortic stenosis and a high transvalvular gradient is straightforward.It requires aortic valve replacement.Management of aortic stenosis patients with low flow,low ejection fraction and low gradient is fraught.Such patients rarely fulfi ll all the tenets of“severity”and also have severe left ventricular dysfunction.Both circumstances make the outcome of aortic valve replacement uncertain.Thus the management of this group of patients requires integration of all diagnostic modalities available.The physical examination,degree of valve calcification,the appearance of the valve during sonographic examination and the presence of inotropic reserve all contribute importantly in judging stenosis severity and the likelihood of successful valve replacement.

An Asymptomatic Patient with Severe Mitral Regurgitation

In primary mitral regurgitation there are anatomic abnormalities of the mitral valve causing backward fl ow,placing a hemodynamic burden on the left ventricle.If this burden is severe and prolonged,it leads to left ventricular damage,heart failure,and death.The preferred therapy is restoration of mitral competence through mitral valve repair,which is safer than mitral valve replacement.When repair is performed in a timely fashion,lifespan can be returned to that of a normal individual.Triggers for timely repair include the onset of symptoms and evidence of left ventricular dysfunction as determined by ejection fraction falling toward 60%and/or end-systolic dimension increasing toward 40 mm.