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Background: Differences in adverse cardiac remodeling between patients who have bicuspid (BAV) and tricuspid aortic valve (TAV) with severe isolated aortic stenosis (AS) and its prognostic impact after surgical aortic valve replacement remains unclear. We sought to investigate differences in preoperative diastolic and systolic function in patients with BAV and TAV who have severe isolated AS and the incidence of postoperative heart failure hospitalization and mortality., Methods: Two hundred seventy-one patients with BAV (n=152) or TAV (n=119) and severe isolated AS without coronary artery disease or other valvular heart disease, scheduled for surgical aortic valve replacement, were prospectively included. Comprehensive preoperative echocardiographic assessment of left ventricular (LV) diastolic and systolic function was performed. The heart failure events were registered during a mean prospective follow-up of 1260 days versus 1441 days for patients with BAV or TAV, respectively., Results: Patients with BAV had a more pronounced LV hypertrophy with significantly higher indexed LV mass ([LVMi] 134 g/m 2 versus 104 g/m 2 , P <0.001), higher prevalence of LV diastolic dysfunction (72% versus 44%, P <0.001), reduced LV ejection fraction (55% versus 60%, P <0.001), significantly impaired global longitudinal strain ( P <0.001), significantly higher NT-proBNP (N-terminal pro-brain natriuretic peptide) levels ( P =0.007), and a higher prevalence of preoperative levosimendan treatment ( P <0.001) than patients with TAV. LVMi was associated with diastolic dysfunction in both patients with BAV and TAV. There was a significant interaction between aortic valve morphology and LVMi on LV ejection fraction, which indicated a pronounced association between LVMi and LV ejection fraction for patients with BAV and lack of association between LVMi and LV ejection fraction for patients with TAV. Postoperatively, the patients with BAV required significantly more inotropic support ( P <0.001). The patients with BAV had a higher cumulative incidence of postoperative heart failure admissions compared with patients with TAV (28.2% versus 10.6% at 6 years after aortic valve replacement, log-rank P =0.004). Survival was not different between patients with BAV and TAV (log-rank P =0.165)., Conclusions: Although they were significantly younger, patients with BAV who had isolated severe AS had worse preoperative LV function and an increased risk of postoperative heart failure hospitalization compared with patients who had TAV. Our findings suggest that patients who have BAV with AS might benefit from closer surveillance and possibly earlier intervention.

Background: Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality., Methods: This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm 2 and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality., Results: Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94-0.99]; P =0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm 2 and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm 2 at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05-2.82]; P =0.03). Furthermore aortic valve area <1cm 2 at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention ( P <0.001). Guideline-defined stroke volume flow reserve did not predict mortality., Conclusions: Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.

Aortic valve stenosis (AS) is the third most common cardiovascular disease. The prevalence of both AS and arterial hypertension increases with age, and the conditions therefore often co-exist. Co-existence of AS and arterial hypertension is associated with higher global left ventricular (LV) pressure overload, more abnormal LV geometry and function, and more adverse cardiovascular outcome. Arterial hypertension may also influence grading of AS, leading to underestimation of the true AS severity. Current guidelines suggest re-assessing patients once arterial hypertension is controlled. Management of arterial hypertension in AS has historically been associated with prudence and concerns, mainly related to potential adverse consequences of drug-induced peripheral vasodilatation combined with reduced stroke volume due to the fixed LV outflow obstruction. Current evidence suggests that patients should be treated with antihypertensive drugs blocking the renin-angiotensin-aldosterone system, adding further drug classes when required, to achieve similar target blood pressure (BP) values as in hypertensive patients without AS. The introduction of transcatheter aortic valve implantation has revolutionized the management of patients with AS, but requires proper BP management during and following valve replacement. The purpose of this document is to review the recent evidence and provide practical expert advice on management of hypertension in patients with AS., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Asymptomatic "paradoxic" severe low-flow low-gradient aortic stenosis with preserved ejection fraction (PAS) constitutes a challenging condition where the optimal management and follow-up remain elusive. We evaluated the clinical outcome in patients with PAS as compared to asymptomatic patients with moderate (MAS) or classical severe aortic stenosis (CAS). Consecutive asymptomatic moderate or severe aortic stenosis patients without concomitant other heart or lung disease (n = 121) were invited. Participants (n = 74) were assigned to three subgroups with regard to degree of aortic stenosis: MAS (n = 25), CAS (n = 22) and PAS (n = 27). Echocardiographic parameters at baseline and clinical outcome data after > 3 years of follow-up time were obtained. Patients with PAS had the smallest stroke volumes and the highest relative wall thickness (p < 0.05). Left ventricular mass index was highest in subjects with CAS, followed closely by PAS and eventually MAS subjects. Whereas ejection fraction was similar amongst the subgroups, a stepwise decrease in global longitudinal left ventricular strain with increasing degree of aortic stenosis was observed, with CAS patients displaying the lowest mean global longitudinal strain, followed by PAS and MAS. A trend towards increasing mortality rate by increasing degree of stenosis was observed. Patients with CAS underwent aortic valve replacement surgery more frequently than both PAS and MAS (p < 0.001). These data suggest that echocardiographic parameters and clinical outcome in patients with PAS bear closer resemblance to CAS than to MAS, but management of PAS is more conservative than in CAS.

Objectives: The study sought to compare echocardiographic with invasive hemodynamic data in patients with "paradoxic" aortic stenosis and in patients with conventionally defined severe aortic stenosis., Background: Controversy exists whether low gradient severe aortic stenosis despite preserved ejection fraction ("paradoxic" aortic stenosis; aortic valve area <1 cm(2), mean gradient <40 mm Hg, ejection fraction >50%), which has been mainly diagnosed by echocardiography (echo), may be largely due to mistakes in echocardiographic measurements., Methods: We compared echocardiographic and invasive hemodynamic data from 58 patients (43% male, mean age 77 ± 5 years) with "paradoxic" aortic stenosis. Data of 22 patients (45% male, mean age 73 ± 7 years) with conventionally defined severe aortic stenosis area (aortic valve area ≤1 cm(2), mean gradient >40 mm Hg, ejection fraction ≥50%) were also analyzed., Results: In patients with "paradoxic" aortic stenosis, orifice area by echo (0.80 ± 0.15 cm(2)) and catheterization showed modest agreement, whether stroke volume was measured by oxymetry (0.69 ± 0.16 cm(2), bias 0.14 ± 0.17 cm(2)), or by thermodilution (0.85 ± 0.19 cm(2), bias -0.03 ± 0.19 cm(2)). Mean systolic gradients were very similar (32 ± 7 mm Hg vs. 31 ± 6 mm Hg; bias -0.08 ± 7.8 mm Hg). In comparison, in patients with conventionally defined severe aortic stenosis, orifice area by echo was 0.72 ± 0.17 cm(2) and by catheterization 0.51 ± 0.15 cm(2) (oxymetry) and 0.68 ± 0.21 cm(2) (thermodilution), respectively, and mean systolic gradient 51 ± 10 mm Hg and 55 ± 8 mm Hg, respectively. Ejection fractions did not differ significantly in both groups. Ascending aortic diameter was significantly smaller in the "paradoxic" aortic stenosis group than in patients with conventionally defined severe aortic stenosis (28 ± 5 mm vs. 31 ± 5 mm), and energy loss index was significantly larger (0.51 ± 0.12 cm(2)/m(2) vs. 0.42 ± 0.09 cm(2)/m(2), respectively). Heart rate and mean blood pressure during echo and catheterization were not significantly different., Conclusions: Occurrence of low gradient severe aortic stenosis despite preserved ejection fraction was confirmed by invasive hemodynamics and was not the result of a systematic bias in the echo calculation of aortic orifice area., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

We compared the measurements of the aortic valve area (AVA) using dual-source computed tomography (DSCT) in patients with mid to severe aortic stenosis to measurements using transthoracic echocardiography (TTE) and invasive hemodynamic assessment. A total of 50 patients (mean age 73 +/- 10 years) with suspected aortic stenosis were included. The computed tomographic data were acquired using DSCT with standardized scan parameters (2 x 64 x 0.6 mm collimation, 330-ms rotation, 120-kV tube voltage, 560 mA/rot tube current). After injection of 35 ml contrast agent (flow rate 5 ml/s), a targeted volume data set, ranging from the top of the leaflets to the infundibulum, was acquired. Ten cross-sectional data sets (slice thickness 1 mm, no overlap, increment 0.6 mm) were reconstructed during systole in 5% increments of the R-R interval. The AVA determined in systole by planimetry was compared to the calculated AVA values using the continuity equation on TTE and the Gorlin formula on catheterization. DSCT allowed the planimetry of the AVA in all patients. The mean AVA using DSCT was 1.16 +/- 0.47 cm(2) compared to a mean AVA of 1.04 +/- 0.45 cm(2) using TTE and 1.06 +/- 0.45 cm(2) using catheterization, with a significant correlation between DSCT/TTE (r = 0.93, p <0.001) and DSCT/cardiac catheterization (r = 0.97, p <0.001). However, DSCT demonstrated a slight, but significant, overestimation of the AVA compared to TTE (+0.12 +/- 0.17 cm) and catheterization (+0.10 +/- 0.12 cm(2)). In conclusion, DSCT permits one to assess the AVA with a high-image quality and diagnostic accuracy compared to TTE and invasive determination.