Compartilhar
Informação da revista
Vol. 36. Núm. 4.
Páginas 287-305 (Abril 2017)
Compartilhar
Compartilhar
Baixar PDF
Mais opções do artigo
Visitas
...
Vol. 36. Núm. 4.
Páginas 287-305 (Abril 2017)
Artigo de revisão
DOI: 10.1016/j.repc.2016.09.010
Open Access
Estenose aórtica paradoxal – revisão sistemática
Paradoxical aortic stenosis: A systematic review
Visitas
...
Rita Cavacaa, Rogério Teixeiraa,b,
Autor para correspondência
rogeriopteixeira@gmail.com

Autor para correspondência.
, Maria João Vieirac, Lino Gonçalvesa,b
a Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
b Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra – Hospital Geral, Coimbra, Portugal
c Serviço de Cardiologia, Hospital de Santarém, Santarém, Portugal
Informação do artigo
Resume
Texto Completo
Bibliografia
Baixar PDF
Estatísticas
Figuras (5)
Mostrar maisMostrar menos
Tabelas (1)
Tabela 1. EA paradoxal e medicina baseada na evidência
Material adicional (1)
Resumo

A estenose aórtica (EA) é uma doença valvular e vascular sistémica, com elevada prevalência nos países desenvolvidos. A nova entidade «EA grave paradoxal, baixo fluxo/baixo gradiente» refere‐se aos casos em que os doentes apresentam EA grave com base na avaliação da área valvular aórtica (AVA) (1cm2) ou AVA indexada (0,6cm2/m2), mas que paradoxalmente tenham um gradiente médio transvalvular baixo (<40mmHg), com baixo volume de ejeção sistólico indexado (≤35ml/m2), apesar de uma fração de ejeção do ventrículo esquerdo preservada (≥50%).

Foi realizada uma pesquisa através da base de dados da PubMed sobre a EA paradoxal no período de 2007‐2014. Para a presente revisão foram incluídos um total de 57 artigos.

A prevalência da EA paradoxal variou entre 3‐35% da população com EA degenerativa grave. Foi mais frequente no género feminino e nos doentes com idade mais avançada, e esteve associada a uma remodelagem característica do ventrículo esquerdo, bem como a um aumento da rigidez vascular arterial sistémica. Assinala‐se a possibilidade de erros e imprecisões no cálculo da AVA pela equação da continuidade, que podem sugerir o fenótipo paradoxal. Existem outros métodos de diagnóstico que podem auxiliar no estudo da EA, como o score de cálcio, a avaliação da impedância valvuloarterial e o estudo da mecânica longitudinal do ventrículo esquerdo. Relativamente à história natural, não é claro que a EA paradoxal corresponda a uma fase avançada da doença valvular aórtica, ou se representa um fenótipo distinto com especificidades próprias. A terapêutica de substituição valvular, cirúrgica ou percutânea, pode estar indicada no doente com EA paradoxal grave e sintomática.

Palavras‐chave:
Estenose aórtica paradoxal
Baixo fluxo sistólico
Baixo gradiente
Rigidez vascular
Diagnóstico
Tratamento
Prognóstico
Abstract

Aortic stenosis (AS) is a complex systemic valvular and vascular disease with a high prevalence in developed countries. The new entity “paradoxical low‐flow, low‐gradient aortic stenosis” refers to cases in which patients have severe AS based on assessment of aortic valve area (AVA) (≤1 cm2) or indexed AVA (≤0.6 cm2/m2), but paradoxically have a low mean transvalvular gradient (<40 mmHg) and a low stroke volume index (≤35 ml/m2), despite preserved left ventricular ejection fraction (≥50%).

A search was carried out in the PubMed database on paradoxical AS for the period 2007‐2014. A total of 57 articles were included for this review. The prevalence of paradoxical AS ranged from 3% to 35% of the population with severe degenerative AS. It was more frequent in females and in older patients. Paradoxical AS was associated with characteristic left ventricular remodeling as well as an increase in systemic arterial stiffness. It was noted that there may be errors and inaccuracies in the calculation of AVA by the continuity equation, which could erroneously suggest the paradoxical phenotype. There are new diagnostic methods to facilitate the study of AS, such as aortic valve calcium score, valvuloarterial impedance and the longitudinal mechanics of the left ventricle. With regard to its natural history, it is not clear whether paradoxical AS corresponds to an advance stage of the disease or if paradoxical AS patients have a distinct phenotype with specific characteristics. Valve replacement, either surgical or percutaneous, may be indicated in patients with severe and symptomatic paradoxical AS.

Keywords:
Paradoxical aortic stenosis
Low systolic flow
Low gradient
Vascular stiffness
Diagnosis
Treatment
Prognosis
Lista de abreviaturas
AVA

Área valvular aórtica

AVAi

Área valvular aórtica indexada

AVAiproj

Área valvular aórtica projetada indexada

BNP

Brain natriuretic peptide

CAS

Compliance arterial sistémica

DC

Doença coronária

DLG

Deformação global longitudinal

EA

Estenose aórtica

EA‐BFBG

Estenose aórtica de baixo fluxo e baixo gradiente

ERP

Espessura relativa da parede

FA

Fibrilhação auricular

FC

Frequência cardíaca

FEVE

Fração de ejeção do ventrículo esquerdo

GM

Gradiente médio transvalvular ventrículo esquerdo/aorta

HTA

Hipertensão arterial

IPE

Índice de perda de energia

PARTNER

Placement of AoRTic TranscathetER Valve Trial Edwards SAPIEN Transcatheter Heart Valve

RMC

Ressonância magnética cardíaca

RVP

Resistência valvular periférica

SEAS

Simvastatin and ezetimibe in aortic stenosis

SC

Superfície corporal

SVAC

Substituição valvular aórtica cirúrgica

SVAP

Substituição valvular aórtica percutânea

TA

Tensão arterial

TSVE

Trato de saída do ventrículo esquerdo

VE

Ventrículo esquerdo

VPEA

Velocidade de pico de ejeção aórtica

VESI

Volume ejeção sistólico indexado

ZVA

Impedância valvuloarterial

Texto Completo
WARNING preg_replace(): Unknown modifier 'p' (includes_ws_v2/librerias/utilidades.php[377])
Referências
[1]
A. Vahanian, O. Alfieri, F. Andreotti, et al.
Guidelines on the management of valvular heart disease (version 2012).
Eur Heart J., 33 (2012), pp. 2451-2496
[2]
B. Iung, A. Vahanian.
Epidemiology of valvular heart disease in the adult.
Nat Rev Cardiol., 8 (2011), pp. 162-172
[3]
R. Nishimura, C.M. Otto, R.O. Bonow, et al.
2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol., 63 (2014), pp. e57-e185
[4]
B. Carabello, L.H. Green, W. Grossman, et al.
Hemodynamic determinants of prognosis of aortic valve replacement in critical aortic stenosis and advanced congestive heart failure.
Circulation., 62 (1980), pp. 42-48
[5]
P. Pibarot, J.G. Dumesnil.
Low‐flow, low‐gradient aortic stenosis with normal and depressed left ventricular ejection fraction.
J Am Coll Cardiol., 60 (2012), pp. 1845-1853
[6]
K. Kusunose, a. Goodman, R. Parikh, et al.
Incremental prognostic value of left ventricular global longitudinal strain in patients with aortic stenosis and preserved ejection fraction.
Circ Cardiovasc Imaging., 7 (2014), pp. 938-945
[7]
M.F. Eleid, P. Sorajja, H.I. Michelena, et al.
Flow‐gradient patterns in severe aortic stenosis with preserved ejection fraction: Clinical characteristics and predictors of survival.
Circulation., 128 (2013), pp. 1781-1789
[8]
Z. Hachicha, J.G. Dumesnil, P. Bogaty, et al.
Paradoxical low‐flow, low‐gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival.
Circulation., 115 (2007), pp. 2856-2864
[9]
M.A. Clavel, P. Pibarot, J.G. Dumesnil.
Paradoxical low flow aortic valve stenosis: incidence, evaluation, and clinical significance.
Curr Cardiol Rep., 16 (2014), pp. 431
[10]
M.A. Clavel, J.G. Dumesnil, R. Capoulade, et al.
Outcome of patients with aortic stenosis, small valve area, and low‐flow, low‐gradient despite preserved left ventricular ejection fraction.
J Am Coll Cardiol., 60 (2012), pp. 1259-1267
[11]
A. Ozkan.
Low gradient “severe” aortic stenosis with preserved left ventricular ejection fraction.
Cardiovasc Diagn Ther., 2 (2012), pp. 19-27
[12]
S. Herrmann, S. Störk, M. Niemann, et al.
Low‐gradient aortic valve stenosis myocardial fibrosis and its influence on function and outcome.
J Am Coll Cardiol., 58 (2011), pp. 402-412
[13]
S.-P. Lee, Y.-J. Kim, J.-H Kim, et al.
Deterioration of myocardial function in paradoxical low‐flow severe aortic stenosis: two‐dimensional strain analysis.
J Am Soc Echocardiogr., 24 (2011), pp. 976-983
[14]
P. Pibarot, J.G. Dumesnil.
Paradoxical low‐flow, low‐gradient aortic stenosis adding new pieces to the puzzle.
J Am Coll Cardiol., 58 (2011), pp. 413-415
[15]
A. Pagé, J.G. Dumesnil, M.A. Clavel, et al.
Metabolic syndrome is associated with more pronounced impairment of left ventricle geometry and function in patients with calcific aortic stenosis: a substudy of the ASTRONOMER (Aortic Stenosis Progression Observation Measuring Effects of Rosuvastatin).
J Am Coll Cardiol., 55 (2010), pp. 1867-1874
[16]
P. Pibarot, J.G. Dumesnil.
Paradoxical low‐flow, low‐gradient aortic stenosis: new evidence, more questions.
Circulation., 128 (2013), pp. 1729-1732
[17]
D. Mohty, J. Magne, M. Deltreuil, et al.
Outcome and impact of surgery in paradoxical low‐flow, low‐gradient severe aortic stenosis and preserved left ventricular ejection fraction: a cardiac catheterization study.
Circulation., 128 (2013), pp. S235-S242
[18]
J.G. Dumesnil, P. Pibarot, B. Carabello.
Paradoxical low flow and/or low gradient severe aortic stenosis despite preserved left ventricular ejection fraction: implications for diagnosis and treatment.
Eur Heart J., 31 (2010), pp. 281-289
[19]
P. Pibarot, J.G. Dumesnil.
Improving assessment of aortic stenosis.
J Am Coll Cardiol., 60 (2012), pp. 169-180
[20]
H. Baumgartner, J. Hung, J. Bermejo, et al.
Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice.
J Am Soc Echocardiogr., 22 (2009), pp. 1-23
quiz 101‐2
[21]
J. Lauten, C. Rost, O. Breithardt, et al.
Invasive hemodynamic characteristics of low gradient severe aortic stenosis despite preserved ejection fraction.
J Am Coll Cardiol., 61 (2013), pp. 1799-1808
[22]
F. Maes, J. Boulif, S. Piérard, et al.
Natural history of paradoxical low‐gradient severe aortic stenosis.
Circ Cardiovasc Imaging., 7 (2014), pp. 714-722
[23]
S. Doddamani, M.J. Grushko, A.N. Makaryus, et al.
Demonstration of left ventricular outflow tract eccentricity by 64‐slice multi‐detector CT.
Int J Cardiovasc Imaging., 25 (2009), pp. 175-181
[24]
S. Doddamani, R. Bello, M. Friedman, et al.
Demonstration of left ventricular outflow tract eccentricity by real time 3D echocardiography: Implications for the determination of aortic valve area.
Echocardiography., 24 (2007), pp. 860-866
[25]
J. Minners, M. Allgeier, C. Gohlke-Baerwolf, et al.
Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis.
Eur Heart J., 29 (2008), pp. 1043-1048
[26]
J.L. Gutiérrez-Chico, J.L. Zamorano, E. Prieto-Moriche, et al.
Real‐time three‐dimensional echocardiography in aortic stenosis: A novel, simple, and reliable method to improve accuracy in area calculation.
Eur Heart J., 29 (2008), pp. 1296-1306
[27]
M.-A. Clavel, P.V. Ennezat, S. Maréchaux, et al.
Stress echocardiography to assess stenosis severity and predict outcome in patients with paradoxical low‐flow, low‐gradient aortic stenosis and preserved LVEF.
JACC Cardiovasc Imaging., 6 (2013), pp. 175-183
[28]
J. Barboza, N. Krishnan, K. Ananthasubramaniam.
Clinical challenges in accurate assessment of severe aortic stenosis with a special focus on low‐gradient aortic stenosis and normal ejection fraction.
Cardiol Rev., 19 (2011), pp. 239-245
[29]
Z. Hachicha, J.G. Dumesnil, P. Pibarot.
Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis.
J Am Coll Cardiol., 54 (2009), pp. 1003-1011
[30]
F. Levy, J. Luc Monin, D. Rusinaru, et al.
Valvuloarterial impedance does not improve risk stratification in low‐ejection fraction, low‐gradient aortic stenosis: Results from a multicentre study.
Eur J Echocardiogr., 12 (2011), pp. 358-363
[31]
S. Maréchaux, É. Carpentier, M. Six-Carpentier, et al.
Impact of valvuloarterial impedance on left ventricular longitudinal deformation in patients with aortic valve stenosis and preserved ejection fraction.
Arch Cardiovasc Dis., 103 (2010), pp. 227-235
[32]
D. Cramariuc, G. Cioffi, A.E. Rieck, et al.
Low‐flow aortic stenosis in asymptomatic patients: valvular‐arterial impedance and systolic function from the SEAS Substudy.
JACC Cardiovasc Imaging., (2009), pp. 390-399
[33]
H. Geyer, G. Caracciolo, H. Abe, et al.
Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications.
J Am Soc Echocardiogr., 23 (2010), pp. 351-369
[34]
P. Lancellotti, E. Donal, J. Magne, et al.
Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay.
Heart., 96 (2010), pp. 1364-1371
[35]
D. Attias, L. MacRon, J. Dreyfus, et al.
Relationship between longitudinal strain and symptomatic status in aortic stenosis.
J Am Soc Echocardiogr., 26 (2013), pp. 868-874
[36]
K. Sato, Y. Seo, T. Ishizu, et al.
Prognostic value of global longitudinal strain in paradoxical low‐flow, low‐gradient severe aortic stenosis with preserved ejection fraction.
Circ J., 78 (2014), pp. 2750-2759
[37]
F. Weidemann, S. Herrmann, S. Störk, et al.
Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis.
Circulation., 120 (2009), pp. 577-584
[38]
I. Ben-Dor, S. Minha, I.M. Barbash, et al.
Correlation of brain natriuretic peptide levels in patients with severe aortic stenosis undergoing operative valve replacement or percutaneous transcatheter intervention with clinical, echocardiographic, and hemodynamic factors and prognosis.
Am J Cardiol., 112 (2013), pp. 574-579
[39]
C. Cueff, J.-M. Serfaty, C. Cimadevilla, et al.
Measurement of aortic valve calcification using multislice computed tomography: correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction.
Heart., 97 (2011), pp. 721-726
[40]
D. Messika-Zeitoun, M.C. Aubry, D. Detaint, et al.
Evaluation and clinical implications of aortic valve calcification measured by electron‐beam computed tomography.
Circulation., 110 (2004), pp. 356-362
[41]
M.A. Clavel, N. Côté, P. Mathieu, et al.
Paradoxical low‐flow, low‐gradient aortic stenosis despite preserved left ventricular ejection fraction: new insights from weights of operatively excised aortic valves.
Eur Heart J., 35 (2014), pp. 2655-2662
[42]
E. Bahlmann, D. Cramariuc, E. Gerdts, et al.
Impact of pressure recovery on echocardiographic assessment of asymptomatic aortic stenosis: a SEAS substudy.
JACC Cardiovasc Imaging., 3 (2010), pp. 555-562
[43]
D. Garcia, J.G. Dumesnil, L.G. Durand, et al.
Discrepancies between catheter and Doppler estimates of valve effective orifice area can be predicted from the pressure recovery phenomenon.
J Am Coll Cardiol, 41 (2003), pp. 435-442
[44]
E. Bahlmann, E. Gerdts, D. Cramariuc, et al.
Prognostic value of energy loss index in asymptomatic aortic stenosis.
Circulation., 127 (2013), pp. 1149-1156
[45]
J. Petrini, M. Yousry, A. Rickenlund, et al.
The feasibility of velocity vector imaging by transesophageal echocardiography for assessment of elastic properties of the descending aorta in aortic valve disease.
J Am Soc Echocardiogr., 23 (2010), pp. 985-992
[46]
R. Teixeira, N. Moreira, R. Baptista, et al.
Circumferential ascending aortic strain and aortic stenosis.
Eur Heart J Cardiovasc Imaging., 14 (2013), pp. 631-641
[47]
K. Piestrzeniewicz, K. Łuczak, M. Maciejewski, et al.
Clinical outcome, echocardiographic assessment, neurohormonal and collagen turnover markers in low‐flow severe aortic stenosis with high transvalvular gradient.
Pol Arch Med Wewn., 124 (2014), pp. 19-26
[48]
P. Pibarot, J.G. Dumesnil.
Assessment of aortic stenosis severity: when the gradient does not fit with the valve area.
Heart., 96 (2010), pp. 1431-1433
[49]
P. Lancellotti, J. Magne, E. Donal, et al.
Clinical outcome in asymptomatic severe aortic stenosis: insights from the new proposed aortic stenosis grading classification.
J Am Coll Cardiol., 59 (2012), pp. 235-243
[50]
H.C. Herrmann, P. Pibarot, I. Hueter, et al.
Predictors of mortality and outcomes of therapy in low‐flow severe aortic stenosis: a Placement of Aortic Transcatheter Valves (PARTNER) trial analysis.
Circulation., 127 (2013), pp. 2316-2326
[51]
N. Jander, W. Hochholzer, B. Kaufmann, et al.
Velocity ratio predicts outcomes in patients with low gradient severe aortic stenosis and preserved EF.
Heart., 100 (2014), pp. 1946-1953
[52]
N. Jander, J. Minners, I. Holme, et al.
Outcome of patients with low‐gradient severe aortic stenosis and preserved ejection fraction.
Circulation., 123 (2011), pp. 887-895
[53]
M.F. Eleid, R. Nishimura, P. Sorajja, et al.
Systemic hypertension in low‐gradient severe aortic stenosis with preserved ejection fraction.
Circulation., 128 (2013), pp. 1349-1353
[54]
A. Ozkan, R. Hachamovitch, S.R. Kapadia, et al.
Impact of aortic valve replacement on outcome of symptomatic patients with severe aortic stenosis with low gradient and preserved left ventricular ejection fraction.
Circulation., 128 (2013), pp. 622-631
[55]
D. Mohty, C. Boulogne, J. Magne, et al.
Prevalence and long‐term outcome of aortic prosthesis‐patient mismatch in patients with paradoxical low‐flow severe aortic stenosis.
Circulation., 130 (2014), pp. S25-S31
[56]
C.J. O'Sullivan, S. Stortecky, D. Heg, et al.
Clinical outcomes of patients with low‐flow, low‐gradient, severe aortic stenosis and either preserved or reduced ejection fraction undergoing transcatheter aortic valve implantation.
Eur Heart J., 34 (2013), pp. 3437-3450
[57]
A. Lauten, R. Figulla, J. Köttins, et al.
TAVI for Iow‐flow, low‐gradient severe aortic stenosis with preserved or reduced ejection fraction: a subgroup analysis from the German Aortic Valve Registry (GARY).
EuroIntervention., 2 (2014), pp. 850-859
Copyright © 2016. Sociedade Portuguesa de Cardiologia
Idiomas
Revista Portuguesa de Cardiologia

Receba a nossa Newsletter

Opções de artigo
Ferramentas
Material Suplementar
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

en pt
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.