{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T18:39:47Z","timestamp":1792521587822,"version":"4.5.0"},"reference-count":21,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"10","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circ: Cardiovascular Imaging"],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND:<\/jats:title>\n                    <jats:p>\n                      Guidelines advocate the use of dobutamine stress echocardiography (DSE) in low-gradient aortic stenosis (aortic valve area [AVA] &lt;1 cm\n                      <jats:sup>2<\/jats:sup>\n                      with aortic valve mean gradient &lt;40 mm\u2009Hg) with reduced left ventricular ejection fraction (&lt;50%) for subsequent patient management. A significant proportion of patients have nondiagnostic DSE (indeterminate aortic stenosis [AS]).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS:<\/jats:title>\n                    <jats:p>\n                      We aimed to assess the impact of DSE on the management of patients with classical low-gradient AS and the use of the newly proposed transvalvular flow\u2013based criteria for AS classification. Accordingly, we retrospectively analyzed 287 patients with classical low-gradient AS who underwent DSE. Both the conventional (severe AS when AVA &lt;1 cm\n                      <jats:sup>2<\/jats:sup>\n                      and aortic valve mean gradient \u226540 mm\u2009Hg, moderate AS when AVA \u22651 cm\n                      <jats:sup>2<\/jats:sup>\n                      , and indeterminate AS when AVA &lt;1 cm\n                      <jats:sup>2<\/jats:sup>\n                      and aortic valve mean gradient &lt;40 mm\u2009Hg during stress) and the proposed combined transvalvular flow criteria (severe AS when AVA &lt;1 cm\n                      <jats:sup>2<\/jats:sup>\n                      at a flow rate \u2265210 mL\/s or projected AVA &lt;1 cm\n                      <jats:sup>2<\/jats:sup>\n                      ) were assessed.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS:<\/jats:title>\n                    <jats:p>\n                      After DSE, 84 (29%) patients had severe AS, 81 (28%) had moderate AS, and 122 (43%) had indeterminate AS. Over the median follow-up of 12.0 (interquartile range, 5\u201333) months, more patients with severe AS (73%) underwent aortic valve intervention compared with those with moderate (40%) and indeterminate AS (44%;\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      &lt;0.001). Use of the newly proposed criteria in the indeterminate AS group improved the proportion of diagnostic tests in the overall population from 57% to 91% and reduced the proportion of indeterminate AS to 9%. Aortic valve intervention was beneficial in patients with reclassified severe AS (HR, 0.50 [95% CI, 0.27\u20130.92];\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      =0.03), whereas the benefit was uncertain in the remaining indeterminate AS group (HR, 0.77 [95% CI, 0.22\u20132.75];\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      =0.69). After aortic valve intervention, patients with conventionally diagnosed severe AS had a better outcome compared with patients with reclassified severe AS (HR, 2.88 [95% CI, 1.34\u20136.21];\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      =0.007).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>In this real-world study, the transvalvular flow\u2013based criteria for severe AS markedly reduced the number of indeterminate DSE. Within the indeterminate AS group, patients with reclassified severe AS derived benefit from aortic valve intervention.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/circimaging.125.018621","type":"journal-article","created":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T09:00:15Z","timestamp":1790154015000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Novel Transvalvular Flow Criteria Reduce Indeterminate Stress Echocardiography and Refine Risk Stratification in Low-Gradient Aortic Stenosis"],"prefix":"10.1161","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3667-8887","authenticated-orcid":true,"given":"Anastasia","family":"Vamvakidou","sequence":"first","affiliation":[{"name":"Department of Echocardiography, Royal Brompton Hospital, London, UK (A.V., J.F.O.R., O.D., R.K., R.S.)."},{"name":"National Heart and Lung Institute, Imperial College, London, UK (A.V., R.K., R.S.)."},{"name":"Department of Cardiac Research, Northwick Park Hospital, Harrow, UK (A.V., R.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2835-9472","authenticated-orcid":true,"given":"Mohamed-Salah","family":"Annabi","sequence":"additional","affiliation":[{"name":"Institut Universitaire de Cardiologie et de Pneumologie, Universit\u00e9 Laval, Qu\u00e9bec, Canada (M.-S.A., E.G., A.D., M.-A.C., P.P.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edyta","family":"Plonska-Gosciniak","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Pomeranian Medical University, Szczecin, Poland (E.P.-G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0360-4363","authenticated-orcid":true,"given":"Ana G.","family":"Almeida","sequence":"additional","affiliation":[{"name":"Faculty of Medicine of Lisbon University; University Hospital ULS Santa Maria, CCUL@RISE, Portugal (A.G.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5489-6450","authenticated-orcid":true,"given":"Tao","family":"Chen","sequence":"additional","affiliation":[{"name":"Global Health Trials Unit, Liverpool School of Tropical Medicine, UK (T.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ezequiel","family":"Guzzetti","sequence":"additional","affiliation":[{"name":"Institut Universitaire de Cardiologie et de Pneumologie, Universit\u00e9 Laval, Qu\u00e9bec, Canada (M.-S.A., E.G., A.D., M.-A.C., P.P.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdellaziz","family":"Dahou","sequence":"additional","affiliation":[{"name":"Institut Universitaire de Cardiologie et de Pneumologie, Universit\u00e9 Laval, Qu\u00e9bec, Canada (M.-S.A., E.G., A.D., M.-A.C., P.P.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1083-2284","authenticated-orcid":true,"given":"Ian G.","family":"Burwash","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthias","family":"Koschutnik","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9061-4839","authenticated-orcid":true,"given":"Philipp E.","family":"Bartko","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2591-1380","authenticated-orcid":true,"given":"Jutta","family":"Bergler-Klein","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julia","family":"Mascherbauer","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine 3, Karl Landsteiner University of Health Sciences, University Hospital St P\u00f6lten, Austria (J.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan","family":"Orwat","sequence":"additional","affiliation":[{"name":"Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Germany (S.O., H.B.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9542-8821","authenticated-orcid":true,"given":"Helmut","family":"Baumgartner","sequence":"additional","affiliation":[{"name":"Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Germany (S.O., H.B.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3632-2074","authenticated-orcid":true,"given":"Jo\u00e3o L.","family":"Cavalcante","sequence":"additional","affiliation":[{"name":"Allina Health Minneapolis Heart Institute, MN (J.L.C.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9360-8581","authenticated-orcid":true,"given":"Danuta","family":"Sorysz","sequence":"additional","affiliation":[{"name":"II Department of Cardiology, CMUJ University Hospital, Krakow, Poland (D.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3807-8201","authenticated-orcid":true,"given":"Wojciech","family":"Kosmala","sequence":"additional","affiliation":[{"name":"Institute of Heart Diseases, Faculty of Medicine, Wroclaw Medical University, Poland (W.K.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3616-8932","authenticated-orcid":true,"given":"Zbigniew","family":"Gasior","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Medical University of Silesia, Katowice, Poland (Z.G.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan Felipe","family":"Ortega Restrepo","sequence":"additional","affiliation":[{"name":"Department of Echocardiography, Royal Brompton Hospital, London, UK (A.V., J.F.O.R., O.D., R.K., R.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oleksandr","family":"Danylenko","sequence":"additional","affiliation":[{"name":"Department of Echocardiography, Royal Brompton Hospital, London, UK (A.V., J.F.O.R., O.D., R.K., R.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rajdeep","family":"Khattar","sequence":"additional","affiliation":[{"name":"Department of Echocardiography, Royal Brompton Hospital, London, UK (A.V., J.F.O.R., O.D., R.K., R.S.)."},{"name":"National Heart and Lung Institute, Imperial College, London, UK (A.V., R.K., R.S.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8924-740X","authenticated-orcid":true,"given":"Marie-Annick","family":"Clavel","sequence":"additional","affiliation":[{"name":"Institut Universitaire de Cardiologie et de Pneumologie, Universit\u00e9 Laval, Qu\u00e9bec, Canada (M.-S.A., E.G., A.D., M.-A.C., 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