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Synetos A, Vlasopoulou K, Drakopoulou M, Apostolos A, Ktenopoulos N, Katsaros O, Korovesis T, Latsios G, Tsioufis K. Impact of Stress Echocardiography on Aortic Valve Stenosis Management. J Clin Med 2024; 13:3495. [PMID: 38930024 PMCID: PMC11204470 DOI: 10.3390/jcm13123495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/23/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Rest and stress echocardiography (SE) play a fundamental role in the evaluation of aortic valve stenosis (AS). According to the current guidelines for the echocardiographic evaluation of patients with aortic stenosis, four broad categories can be defined: high-gradient AS (mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, aortic valve area (AVA) ≤ 1 cm2 or indexed AVA ≤ 0.6 cm2/m2); low-flow, low-gradient AS with reduced ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, left ventricle ejection fraction (LVEF) < 50%, stroke volume index (Svi) ≤ 35 mL/m2); low-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, LVEF ≥ 50%, SVi ≤ 35 mL/m2); and normal-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, indexed AVA ≤ 0.6 cm2/m2, LVEF ≥ 50%, SVi > 35 mL/m2). Aortic valve replacement (AVR) is indicated with the onset of symptoms development or LVEF reduction. However, there is often mismatch between resting transthoracic echocardiography findings and patient's symptoms. In these discordant cases, SE and CT calcium scoring are among the indicated methods to guide the management decision making. Additionally, due to the increasing evidence that in asymptomatic severe aortic stenosis an early AVR instead of conservative treatment is associated with better outcomes, SE can help identify those that would benefit from an early AVR by revealing markers of poor prognosis. Low-flow, low-gradient AS represents a challenge both in diagnosis and in therapeutic management. Low-dose dobutamine SE is the recommended method to distinguish true-severe from pseudo-severe stenosis and assess the existence of flow (contractile) reserve to appropriately guide the need for intervention in these patients.
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Affiliation(s)
- Andreas Synetos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
- School of Medicine, European University of Cyprus, 2404 Egkomi, Cyprus
| | - Konstantina Vlasopoulou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Maria Drakopoulou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Anastasios Apostolos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Odysseas Katsaros
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Theofanis Korovesis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - George Latsios
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Kostas Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
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Santos-Ferreira D, Fernandes I, Diaz SO, Guerreiro C, Saraiva F, Barros AS, Leite-Moreira A, Pereira E, Sampaio F, Ribeiro J, Braga P, Fontes-Carvalho R. Prognostic value of flow-status in severe aortic stenosis patients undergoing percutaneous intervention. Int J Cardiovasc Imaging 2024; 40:341-350. [PMID: 37981631 PMCID: PMC10884040 DOI: 10.1007/s10554-023-02992-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/21/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE Low-flow status is a mortality predictor in severe aortic stenosis (SAS) patients, including after transcatheter aortic valve implantation (TAVI) treatment. However, the best parameter to assess flow is unknown. Recent studies suggest that transaortic flow rate (FR) is superior to currently used stroke volume index (SVi) in defining low-flow states. Therefore, we aimed to evaluate the prognostic value of FR and SVi in patients undergoing TAVI. METHODS A single-centre retrospective analysis of all consecutive patients treated with TAVI for SAS between 2011 and 2019 was conducted. Low-FR was defined as < 200 mL/s and low-SVi as < 35 mL/m2. Primary endpoint was all-cause five-year mortality, analyzed using Kaplan-Meier curves and Cox regression models. Secondary endpoint was variation of NYHA functional class six months after procedure. Patients were further stratified according to ejection fraction (EF < 50%). RESULTS Of 489 cases, 59.5% were low-FR, and 43.1% low-SVi. Low-flow patients had superior surgical risk, worse renal function, and had a higher prevalence of coronary artery disease. Low-FR was associated with mortality (hazard ratio 1.36, p = 0.041), but not after adjustment to EuroSCORE II. Normal-SVi was not associated with survival, despite a significative p-trend for its continuous value. No associations were found for flow-status and NYHA recovery. When stratifying according to preserved and reduced EF, both FR and SVi did not predict all-cause mortality. CONCLUSION In patients with SAS undergoing TAVI, a low-FR state was associated with higher mortality, as well as SVi, but not at a 35 mL/m2 cut off.
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Affiliation(s)
- Diogo Santos-Ferreira
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Isabel Fernandes
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Sílvia O Diaz
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Cláudio Guerreiro
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
| | - Francisca Saraiva
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - António S Barros
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - Eulália Pereira
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
| | - Francisco Sampaio
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal
| | - José Ribeiro
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
| | - Pedro Braga
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal
| | - Ricardo Fontes-Carvalho
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, Vila Nova de Gaia, 4434-502, Portugal.
- Department of Surgery and Physiology, UnIC@RISE, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal.
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Vamvakidou A, Annabi MS, Pibarot P, Plonska-Gosciniak E, Almeida AG, Guzzetti E, Dahou A, Burwash IG, Koschutnik M, Bartko PE, Bergler-Klein J, Mascherbauer J, Orwat S, Baumgartner H, Cavalcante J, Pinto F, Kukulski T, Kasprzak JD, Clavel MA, Flachskampf FA, Senior R. Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study. Circ Cardiovasc Imaging 2021; 14:e012809. [PMID: 34743529 DOI: 10.1161/circimaging.121.012809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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 cm2 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 <1cm2 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 cm2 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 <1cm2 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.
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Affiliation(s)
- Anastasia Vamvakidou
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom (A.V., R.S.).,National Heart and Lung Institute, Imperial College, London, United Kingdom (A.V., R.S.).,Department of Cardiovascular Research, Northwick Park Hospital, Harrow, United Kingdom (A.V., R.S.)
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Phillipe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | | | - Ana G Almeida
- Lisbon University, Hospital Santa Maria/CHULN, Portugal (A.G.A., F.P.)
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Abdellaziz Dahou
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Ian G Burwash
- University of Ottawa Heart Institute, Canada (I.G.B.)
| | - Matthias Koschutnik
- Department of Cardiology, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)
| | - Philipp E Bartko
- Department of Cardiology, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)
| | - Jutta Bergler-Klein
- Department of Cardiology, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)
| | - Julia Mascherbauer
- Department of Internal Medicine 3, Karl Landsteiner University of Health Sciences, University Hospital St. Polten, Krems, Austria (J.M.)
| | - Stefan Orwat
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Germany (S.O., H.B.)
| | - Helmut Baumgartner
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Germany (S.O., H.B.)
| | - Joao Cavalcante
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Fausto Pinto
- Lisbon University, Hospital Santa Maria/CHULN, Portugal (A.G.A., F.P.)
| | - Tomasz Kukulski
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Zabrze, Poland (T.K.)
| | - Jaroslaw D Kasprzak
- I Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Poland (J.D.K.)
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Frank A Flachskampf
- Department of Medical Sciences, Uppsala University, Sweden (F.A.F.).,Department of Clinical Physiology, Akademiska University Hospital, Uppsala, Sweden (F.A.F.)
| | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom (A.V., R.S.).,National Heart and Lung Institute, Imperial College, London, United Kingdom (A.V., R.S.).,Department of Cardiovascular Research, Northwick Park Hospital, Harrow, United Kingdom (A.V., R.S.)
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Salahuddin A, Aronow WS, Spevack DM. At what flow rate does the aortic valve gradient become severely elevated? Implications for guideline recommendations on aortic valve area cutoffs. Arch Med Sci 2021; 20:713-718. [PMID: 39050168 PMCID: PMC11264064 DOI: 10.5114/aoms/118938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/12/2020] [Indexed: 07/27/2024] Open
Abstract
Introduction Aortic stenosis (AS) is considered severe when the aortic valve area (AVA) is < 1.0 cm2 and the mean aortic valve gradient (mAVG) exceeds 40 mm Hg. Since many patients with AVA < 1.0 cm2 do not manifest an mAVG > 40 mm Hg, we sought to determine the AVA at which mAVG tends to exceed 40 mm Hg in a sample of subjects with varied transvalvular flow rates. Material and methods Our echocardiography database was queried for subjects with native valve AS. We selected 200 subjects with an AVA < 1.0 cm2. The sample was selected to include subjects with varied mean systolic flow (MSF) rates. Linear regression was performed to determine the relationship between MSF and mAVG. Since this relationship varied by AVA, the regression was stratified by AVA (critical < 0.6 cm2, severe 0.6-0.79 cm2, moderately severe 0.8-0.99 cm2). Results The study sample was 79 ±12 years old and was 60% female. The MSF rate at which mAVG tended to exceed 40 mm Hg was 120 ml/s for critical AVA, 183 ml/s for severe AVA and 257 ml/s for moderately severe AVA. Those with moderately severe AVA rarely (8%) had an mAVG > 40 mm Hg at a wide range of MSF. In contrast, those with severe AVA typically (75%) had mAVG > 40 mm Hg when MSF was normal (> 200 ml/s). Those with critical AVA frequently (44%) had mAVG > 40 mm Hg, even when MSF was reduced. Conclusions Subjects with AVA of 0.8 and 0.9 cm2 rarely had mAVG > 40 mm Hg, even when the transvalvular flow rate was normal. Using current guidelines, it is not clear if such cases should be classified as severe.
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Affiliation(s)
- Ayesha Salahuddin
- Department of Medicine, Cardiology Division, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Wilbert S. Aronow
- Department of Cardiology, Westchester Medical Center and the Department of Medicine, New York Medical College, Valhalla, New York, USA
| | - Daniel M. Spevack
- Department of Medicine, Cardiology Division, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Cardiology, Westchester Medical Center and the Department of Medicine, New York Medical College, Valhalla, New York, USA
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Pibarot P, Sengupta P, Chandrashekhar Y. Imaging Is the Cornerstone of the Management of Aortic Valve Stenosis. JACC Cardiovasc Imaging 2020; 12:220-223. [PMID: 30621995 DOI: 10.1016/j.jcmg.2018.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Philippe Pibarot
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Partho Sengupta
- Division of Cardiology, West Virginia University Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Y Chandrashekhar
- Division of Cardiology, University of Minnesota and Veterans Affairs Medical Center, Minneapolis, Minnesota.
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Vollema EM, Delgado V, Bax JJ. Echocardiography in Transcatheter Aortic Valve Replacement. Heart Lung Circ 2019; 28:1384-1399. [DOI: 10.1016/j.hlc.2018.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 12/11/2018] [Accepted: 12/16/2018] [Indexed: 02/06/2023]
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Vamvakidou A, Jin W, Danylenko O, Chahal N, Khattar R, Senior R. Low Transvalvular Flow Rate Predicts Mortality in Patients With Low-Gradient Aortic Stenosis Following Aortic Valve Intervention. JACC Cardiovasc Imaging 2019; 12:1715-1724. [DOI: 10.1016/j.jcmg.2018.01.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 10/17/2022]
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The impact of aortic valve replacement on survival in patients with normal flow low gradient severe aortic stenosis: a propensity-matched comparison. Eur Heart J Cardiovasc Imaging 2019; 20:1094-1101. [DOI: 10.1093/ehjci/jez191] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/03/2019] [Indexed: 12/23/2022] Open
Abstract
Abstract
Aims
To assess the survival benefit of aortic valve replacement (AVR) in patients with normal flow low gradient severe aortic stenosis (AS).
Methods and results
A retrospective study of prospectively collected data of 276 patients (mean age 75 ± 15 years, 51% male) with normal transaortic flow [flow rate (FR) ≥200 mL/s or stroke volume index (SVi) ≥35 mL/m2] and severe AS (aortic valve area <1.0 cm2). The outcome measure was all-cause mortality. Of the 276 patients, 151 (55%) were medically treated, while 125 (45%) underwent an AVR. Over a mean follow-up of 3.2 ± 1.8 years (range 0–6.9 years), a total of 96 (34.8%) deaths occurred: 17 (13.6%) in AVR group vs. 79 (52.3%) in those medically treated, when transaortic flow was defined by FR (P < 0.001). When transaortic flow was defined by SVi, a total of 79 (31.3%) deaths occurred: 18 (15.1%) in AVR group vs. 61 (45.9%) in medically treated (P < 0.001). In a propensity-matched multivariable Cox regression analysis adjusting for age, gender, body surface area, smoking, hypertension, diabetes mellitus, atrial fibrillation, peripheral vascular disease, chronic kidney disease, left ventricular ejection fraction, left ventricular mass, and mean aortic gradient, not having AVR was associated with a 6.3-fold higher hazard ratio (HR) of all-cause mortality [HR 6.28, 95% confidence interval (CI) 3.34–13.16; P < 0.001] when flow was defined by FR. In the SVi-guided model, it was 3.83-fold (HR 3.83, 95% CI 2.30–6.37; P < 0.001).
Conclusion
In patients with normal flow low gradient severe AS, AVR was associated with a significantly improved survival compared with those who received standard medical treatment.
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Lazaros G, Drakopoulou M, Tousoulis D. Transaortic Flow in Aortic Stenosis: Stroke Volume Index versus Flow Rate. Cardiology 2018; 141:71-73. [DOI: 10.1159/000494051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 09/24/2018] [Indexed: 11/19/2022]
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Saeed S, Senior R, Chahal NS, Lønnebakken MT, Chambers JB, Bahlmann E, Gerdts E. Lower Transaortic Flow Rate Is Associated With Increased Mortality in Aortic Valve Stenosis. JACC Cardiovasc Imaging 2017; 10:912-920. [DOI: 10.1016/j.jcmg.2017.05.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/15/2017] [Accepted: 05/19/2017] [Indexed: 10/19/2022]
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