{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T13:22:22Z","timestamp":1791292942091,"version":"4.1.0"},"reference-count":15,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"22","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circulation"],"published-print":{"date-parts":[[2007,6,5]]},"abstract":"\n \n Background\u2014<\/jats:italic>\n <\/jats:bold>\n Recent studies and current clinical observations suggest that some patients with severe aortic stenosis on the basis of aortic valve area may paradoxically have a relatively low gradient despite the presence of a preserved left ventricular (LV) ejection fraction. The objective of the present study was to document the prevalence, potential mechanisms, and clinical relevance of this phenomenon.\n <\/jats:p>\n \n \n Methods and Results\u2014<\/jats:italic>\n <\/jats:bold>\n We retrospectively studied the clinical and Doppler echocardiographic data of 512 consecutive patients with severe aortic stenosis (indexed aortic valve area \u22640.6 cm\n 2<\/jats:sup>\n \u00b7 m\n \u22122<\/jats:sup>\n ) and preserved LV ejection fraction (\u226550%). Of these patients, 331 (65%) had normal LV flow output defined as a stroke volume index >35 mL \u00b7 m\n 2<\/jats:sup>\n , and 181 (35%) had paradoxically low-flow output defined as stroke volume index \u226435 mL \u00b7 m\n \u22122<\/jats:sup>\n . When compared with normal flow patients, low-flow patients had a higher prevalence of female gender (\n P<\/jats:italic>\n <0.05), a lower transvalvular gradient (32\u00b117 versus 40\u00b115 mm Hg;\n P<\/jats:italic>\n <0.001), a lower LV diastolic volume index (52\u00b112 versus 59\u00b113 mL \u00b7 m\n \u22122<\/jats:sup>\n ;\n P<\/jats:italic>\n <0.001), lower LV ejection fraction (62\u00b18% versus 68\u00b17%;\n P<\/jats:italic>\n <0.001), a higher level of LV global afterload reflected by a higher valvulo-arterial impedance (5.3\u00b11.3 versus 4.1\u00b10.7 mm Hg \u00b7 mL\n \u22121<\/jats:sup>\n \u00b7 m\n \u22122<\/jats:sup>\n ;\n P<\/jats:italic>\n <0.001) and a lower overall 3-year survival (76% versus 86%;\n P<\/jats:italic>\n =0.006). Only age (hazard ratio, 1.04; 95% CI, 1.01 to 1.08;\n P<\/jats:italic>\n =0.025), valvulo-arterial impedance >5.5 mm Hg \u00b7 mL\n \u22121<\/jats:sup>\n \u00b7 m\n \u22122<\/jats:sup>\n (hazard ratio, 2.6; 95% CI, 1.2 to 5.7;\n P<\/jats:italic>\n =0.017), and medical treatment (hazard ratio, 3.3; 95% CI, 1.8 to 6.7;\n P<\/jats:italic>\n =0.0003) were independently associated with increased mortality.\n <\/jats:p>\n \n \n Conclusion\u2014<\/jats:italic>\n <\/jats:bold>\n Patients with severe aortic stenosis may have low transvalvular flow and low gradients despite normal LV ejection fraction. A comprehensive evaluation shows that this pattern is in fact consistent with a more advanced stage of the disease and has a poorer prognosis. Such findings are clinically relevant because this condition may often be misdiagnosed, which leads to a neglect and\/or an underestimation of symptoms and an inappropriate delay of aortic valve replacement surgery.\n <\/jats:p>","DOI":"10.1161\/circulationaha.106.668681","type":"journal-article","created":{"date-parts":[[2007,5,28]],"date-time":"2007-05-28T20:25:45Z","timestamp":1180383945000},"page":"2856-2864","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":873,"title":["Paradoxical Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Preserved Ejection Fraction Is Associated With Higher Afterload and Reduced Survival"],"prefix":"10.1161","volume":"115","author":[{"given":"Zeineb","family":"Hachicha","sequence":"first","affiliation":[{"name":"From the Laval Hospital Research Center\/Quebec Heart Institute, Department of Medicine, Laval University, Quebec, Canada."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean G.","family":"Dumesnil","sequence":"additional","affiliation":[{"name":"From the Laval Hospital Research Center\/Quebec Heart Institute, Department of Medicine, Laval University, Quebec, Canada."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Bogaty","sequence":"additional","affiliation":[{"name":"From the Laval Hospital Research Center\/Quebec Heart Institute, Department of Medicine, Laval University, Quebec, Canada."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philippe","family":"Pibarot","sequence":"additional","affiliation":[{"name":"From the Laval Hospital Research Center\/Quebec Heart Institute, Department of Medicine, Laval University, Quebec, Canada."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_2_1_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2004.10.081"},{"key":"e_1_3_2_2_2","doi-asserted-by":"publisher","DOI":"10.1136\/hrt.2003.030601"},{"key":"e_1_3_2_3_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2006.03.002"},{"key":"e_1_3_2_4_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.101.7.765"},{"key":"e_1_3_2_5_2","doi-asserted-by":"publisher","DOI":"10.1067\/mje.2002.123396"},{"key":"e_1_3_2_6_2","first-page":"1007","volume":"11","year":"1995","unstructured":"Dumesnil JG, Dion D, Yvorchuk K, Davies RA, Chan K. A new, simple and accurate method for determining ejection fraction by Doppler echocardiography. Can J Cardiol. 1995; 11: 1007\u20131014.","journal-title":"Can J Cardiol"},{"key":"e_1_3_2_7_2","unstructured":"Grossman W. Evaluation of systolic and diastolic function of the ventricles and myocardium. In: Baim DS Grossman W eds. Cardiac Catheterization Angiography and Intervention. Philadelphia PA: Lippincott Williams and Wilkins; 2000; 367\u2013390."},{"key":"e_1_3_2_8_2","doi-asserted-by":"publisher","DOI":"10.1378\/chest.119.6.1766"},{"key":"e_1_3_2_9_2","doi-asserted-by":"publisher","DOI":"10.1161\/circulationaha.106.175132"},{"key":"e_1_3_2_10_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.59.5.428084"},{"key":"e_1_3_2_11_2","doi-asserted-by":"publisher","DOI":"10.1161\/circ.65.1.7053292"},{"key":"e_1_3_2_12_2","doi-asserted-by":"publisher","DOI":"10.1016\/0735-1097(95)00153-Q"},{"key":"e_1_3_2_13_2","doi-asserted-by":"publisher","DOI":"10.1136\/hrt.2004.041749"},{"key":"e_1_3_2_14_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.cir.0000085167.67105.32"},{"key":"e_1_3_2_15_2","doi-asserted-by":"publisher","DOI":"10.1136\/hrt.2005.067363"}],"container-title":["Circulation"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/CIRCULATIONAHA.106.668681","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,5,13]],"date-time":"2024-05-13T01:04:22Z","timestamp":1715562262000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ahajournals.org\/doi\/10.1161\/CIRCULATIONAHA.106.668681"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2007,6,5]]},"references-count":15,"journal-issue":{"issue":"22","published-print":{"date-parts":[[2007,6,5]]}},"alternative-id":["10.1161\/CIRCULATIONAHA.106.668681"],"URL":"https:\/\/doi.org\/10.1161\/circulationaha.106.668681","relation":{"has-review":[{"id-type":"doi","id":"10.3410\/f.1088374.542147","asserted-by":"object"},{"id-type":"doi","id":"10.3410\/f.1088374.541420","asserted-by":"object"}]},"ISSN":["0009-7322","1524-4539"],"issn-type":[{"value":"0009-7322","type":"print"},{"value":"1524-4539","type":"electronic"}],"subject":[],"published":{"date-parts":[[2007,6,5]]},"assertion":[{"value":"2007-05-28","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}