{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,12]],"date-time":"2025-10-12T01:20:34Z","timestamp":1760232034987,"version":"build-2065373602"},"reference-count":55,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2022,5,19]],"date-time":"2022-05-19T00:00:00Z","timestamp":1652918400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Jagiellonian University Medical College"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Paradoxical low-flow\/low-gradient aortic stenosis (P-LFLG-AS) occurs in about one-third of patients with severe AS and preserved left ventricular (LV) ejection fraction (EF). Our aim was to differentiate between altered LV loading conditions and contractility as determinants of subtle LV systolic dysfunction in P-LFLG-AS. We retrospectively analyzed medical records of patients with isolated severe degenerative AS and preserved EF (30 subjects with P-LFLG-AS and 30 patients with normal-flow\/high-gradient severe AS (NFHG-AS)), without relevant coexistent diseases (e.g., diabetes, coronary artery disease and chronic kidney disease) or any abnormalities which could account for a low-flow state. Patients with P-LFLG-AS and NFHG-AS did not differ in aortic valve area index and most clinical characteristics. Compared to NFHG-AS, subjects with P-LFLG-AS exhibited smaller LV end-diastolic diameter (LVd) (44 \u00b1 5 vs. 54 \u00b1 5 mm, p &lt; 0.001) (consistent with lower LV preload) with pronounced concentric remodeling, higher valvulo-arterial impedance (3.8 \u00b1 1.1 vs. 2.2 \u00b1 0.5 mmHg per mL\/m2, p &lt; 0.001) and diminished systemic arterial compliance (0.45 \u00b1 0.11 vs. 0.76 \u00b1 0.23 mL\/m2 per mmHg, p &lt; 0.001), while circumferential end-systolic LV midwall stress (cESS), an estimate of afterload at the LV level, was similar in P-LFLG-AS and NFHG-AS (175 \u00b1 83 vs. 198 \u00b1 69 hPa, p = 0.3). LV midwall fractional shortening (mwFS) was depressed in P-LFLG-AS vs. NFHG-AS (12.3 \u00b1 3.5 vs. 14.7 \u00b1 2.9%, p = 0.006) despite similar EF (61 \u00b1 6 vs. 59 \u00b1 8%, p = 0.4). By multiple regression, the presence of P-LFLG-AS remained a significant predictor of lower mwFS compared to NFHG-AS upon adjustment for cESS (\u03b2 \u00b1 SEM: \u22122.35 \u00b1 0.67, p &lt; 0.001); however, the significance was lost after further correction for LVd (\u03b2 = \u22121.10 \u00b1 0.85, p = 0.21). In conclusion, the association of P-LFLG-AS with a lower cESS-adjusted mwFS, an index of afterload-corrected LV circumferential systolic function at the midwall level, appears secondary to a smaller LV end-diastolic cavity size according to the Frank\u2013Starling law. Thus, low LV preload, not intrinsic contractile dysfunction or excessive afterload, may account for impaired LV circumferential midwall systolic performance in P-LFLG-AS.<\/jats:p>","DOI":"10.3390\/jcm11102873","type":"journal-article","created":{"date-parts":[[2022,5,19]],"date-time":"2022-05-19T12:25:57Z","timestamp":1652963157000},"page":"2873","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Impaired Left Ventricular Circumferential Midwall Systolic Performance Appears Linked to Depressed Preload, but Not Intrinsic Contractile Dysfunction or Excessive Afterload, in Paradoxical Low-Flow\/Low-Gradient Severe Aortic Stenosis"],"prefix":"10.3390","volume":"11","author":[{"given":"Dorota","family":"D\u0142ugosz","sequence":"first","affiliation":[{"name":"Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7949-3140","authenticated-orcid":false,"given":"Andrzej","family":"Surdacki","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland"},{"name":"Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Barbara","family":"Zawi\u015blak","sequence":"additional","affiliation":[{"name":"Intensive Care Unit, Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stanis\u0142aw","family":"Bartu\u015b","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland"},{"name":"Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bernadeta","family":"Chyrchel","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland"},{"name":"Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2022,5,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2645","DOI":"10.1093\/eurheartj\/ehw096","article-title":"Low-gradient aortic stenosis","volume":"37","author":"Clavel","year":"2016","journal-title":"Eur. Heart J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1845","DOI":"10.1016\/j.jacc.2012.06.051","article-title":"Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction","volume":"60","author":"Pibarot","year":"2012","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2739","DOI":"10.1093\/eurheartj\/ehx391","article-title":"2017 ESC\/EACTS Guidelines for the management of valvular heart disease","volume":"38","author":"Baumgartner","year":"2017","journal-title":"Eur. Heart J."},{"key":"ref_4","first-page":"e72","article-title":"2020 ACC\/AHA Guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"143","author":"Otto","year":"2021","journal-title":"Circulation"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2594","DOI":"10.1016\/j.jacc.2015.09.076","article-title":"Outcome and impact of aortic valve replacement in patients with preserved LVEF and low-gradient aortic stenosis","volume":"66","author":"Dayan","year":"2015","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e007977","DOI":"10.1161\/JAHA.117.007977","article-title":"Predictors of mortality and symptomatic outcome of patients with low-flow severe aortic stenosis undergoing transcatheter aortic valve replacement","volume":"7","author":"Mangner","year":"2018","journal-title":"J. Am. Heart Assoc."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"5092","DOI":"10.1038\/s41598-017-05021-9","article-title":"Effects of aortic valve replacement on severe aortic stenosis and preserved systolic function: Systematic review and network meta-analysis","volume":"7","author":"Zheng","year":"2017","journal-title":"Sci. Rep."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2856","DOI":"10.1161\/CIRCULATIONAHA.106.668681","article-title":"Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival","volume":"115","author":"Hachicha","year":"2007","journal-title":"Circulation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1015","DOI":"10.1136\/heartjnl-2014-306838","article-title":"Development of paradoxical low-flow, low-gradient severe aortic stenosis","volume":"101","author":"Dahl","year":"2015","journal-title":"Heart"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Chyrchel, B., D\u0142ugosz, D., Bolt, K., Kruszelnicka, O., Dziewierz, A., \u015awierszcz, J., Wieczorek-Surdacka, E., Hryniewiecki, T., and Surdacki, A. (2018). Association of inadequately low left ventricular mass with enhanced myocardial contractility in severe degenerative aortic stenosis. J. Clin. Med., 7.","DOI":"10.3390\/jcm7120464"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Chyrchel, B., Bolt, K., D\u0142ugosz, D., Urba\u0144ska, A., Nowak-K\u0119pczyk, M., Ba\u0142ata, J., Ro\u017canowska, A., Czestkowska, E., Kruszelnicka, O., and Surdacki, A. (2019). Better myocardial function in aortic stenosis with low left ventricular mass: A mechanism of protection against heart failure regardless of stenosis severity?. J. Clin. Med., 8.","DOI":"10.3390\/jcm8111836"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1186\/s12933-019-0894-1","article-title":"Depressed systemic arterial compliance and impaired left ventricular midwall performance in aortic stenosis with concomitant type 2 diabetes: A retrospective cross-sectional study","volume":"18","author":"Czestkowska","year":"2019","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1486","DOI":"10.5603\/KP.a2018.0196","article-title":"Excessive left ventricular hypertrophy in moderate degenerative aortic stenosis: An ineffective compensatory mechanism triggered by primary myocardial dysfunction and enhanced by concomitant mild renal impairment?","volume":"76","author":"Bolt","year":"2018","journal-title":"Kardiol. Pol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1161\/01.CIR.71.2.266","article-title":"Left ventricular chamber filling and midwall fiber lengthening in patients with left ventricular hypertrophy: Overestimation of fiber velocities by conventional midwall measurements","volume":"71","author":"Shimizu","year":"1985","journal-title":"Circulation"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1444","DOI":"10.1016\/0735-1097(94)90390-5","article-title":"Assessment of left ventricular function by the midwall fractional shortening\/end-systolic stress relation in human hypertension","volume":"23","author":"Devereux","year":"1994","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1016\/0735-1097(95)00153-Q","article-title":"Geometric changes allow normal ejection fraction despite depressed myocardial shortening in hypertensive left ventricular hypertrophy","volume":"26","author":"Aurigemma","year":"1995","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2415","DOI":"10.1161\/01.CIR.88.5.2415","article-title":"Transition from compensated hypertrophy to intrinsic myocardial dysfunction during development of left ventricular pressure-overload hypertrophy in conscious sheep. Systolic dysfunction precedes diastolic dysfunction","volume":"88","author":"Aoyagi","year":"1993","journal-title":"Circulation"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e001021","DOI":"10.1136\/openhrt-2019-001021","article-title":"End-systolic wall stress in aortic stenosis: Comparing symptomatic and asymptomatic patients","volume":"6","author":"Moller","year":"2019","journal-title":"Open Heart"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1629","DOI":"10.1136\/heartjnl-2018-314462","article-title":"Higher left ventricular mass-wall stress-heart rate product and outcome in aortic valve stenosis","volume":"105","author":"Gerdts","year":"2019","journal-title":"Heart"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1161\/01.CIR.65.1.99","article-title":"Noninvasive determination of left ventricular end-systolic stress: Validation of the method and initial application","volume":"65","author":"Reichek","year":"1982","journal-title":"Circulation"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"872","DOI":"10.1161\/01.CIR.79.4.872","article-title":"Stress-shortening relations and myocardial blood flow in compensated and failing canine hearts with pressure-overload hypertrophy","volume":"79","author":"Gaasch","year":"1989","journal-title":"Circulation"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"478","DOI":"10.1136\/heartjnl-2014-307151","article-title":"LV peak instantaneous wall stress versus time-stress-integral as measures of afterload in aortic stenosis","volume":"101","author":"Sohn","year":"2015","journal-title":"Heart"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1161\/01.CIR.62.1.42","article-title":"Hemodynamic determinants of prognosis of aortic valve replacement in critical aortic stenosis and advanced congestive heart failure","volume":"62","author":"Carabello","year":"1980","journal-title":"Circulation"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1093\/ehjci\/jev014","article-title":"Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging","volume":"16","author":"Lang","year":"2015","journal-title":"Eur. Heart J. Cardiovasc. Imaging"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1016\/j.jacc.2004.10.081","article-title":"Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: Implications for diagnosis and treatment","volume":"46","author":"Briand","year":"2005","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"890","DOI":"10.1016\/0735-1097(90)90289-2","article-title":"Preload dependence of fiber shortening rate in conscious dogs with left ventricular hypertrophy","volume":"15","author":"Mirsky","year":"1990","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"931","DOI":"10.1007\/s00392-019-01423-z","article-title":"Hemodynamics of paradoxical severe aortic stenosis: Insight from a pressure-volume loop analysis","volume":"108","author":"Gotzmann","year":"2019","journal-title":"Clin. Res. Cardiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1161\/CIRCHEARTFAILURE.112.000164","article-title":"Invasive measures of afterload in low gradient severe aortic stenosis with preserved ejection fraction","volume":"6","author":"Eleid","year":"2013","journal-title":"Circ. Heart Fail"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1016\/j.jcmg.2019.01.009","article-title":"Left ventricular contractility and wall stress in patients with aortic stenosis with preserved or reduced ejection fraction","volume":"13","author":"Ito","year":"2020","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"976","DOI":"10.1016\/j.echo.2011.05.003","article-title":"Deterioration of myocardial function in paradoxical low-flow severe aortic stenosis: Two-dimensional strain analysis","volume":"24","author":"Lee","year":"2011","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1161\/CIRCIMAGING.111.967554","article-title":"Low-flow, low-gradient severe aortic stenosis despite normal ejection fraction is associated with severe left ventricular dysfunction as assessed by speckle-tracking echocardiography: A multicenter study","volume":"5","author":"Adda","year":"2012","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"87","DOI":"10.2459\/JCM.0000000000000324","article-title":"Paradoxical low-flow aortic stenosis is defined by increased ventricular hydraulic load and reduced longitudinal strain","volume":"18","author":"Holmes","year":"2017","journal-title":"J. Cardiovasc. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2750","DOI":"10.1253\/circj.CJ-14-0726","article-title":"Prognostic value of global longitudinal strain in paradoxical low-flow, low-gradient severe aortic stenosis with preserved ejection fraction","volume":"78","author":"Sato","year":"2014","journal-title":"Circ. J."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"402","DOI":"10.1016\/j.jacc.2011.02.059","article-title":"Low-gradient aortic valve stenosis myocardial fibrosis and its influence on function and outcome","volume":"58","author":"Herrmann","year":"2011","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1136","DOI":"10.1161\/CIRCULATIONAHA.104.516963","article-title":"Increased cardiac expression of tissue inhibitor of metalloproteinase-1 and tissue inhibitor of metalloproteinase-2 is related to cardiac fibrosis and dysfunction in the chronic pressure-overloaded human heart","volume":"112","author":"Heymans","year":"2005","journal-title":"Circulation"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e007547","DOI":"10.1161\/CIRCINTERVENTIONS.118.007547","article-title":"Coronary microcirculation in aortic stenosis","volume":"12","author":"McConkey","year":"2019","journal-title":"Circ. Cardiovasc. Interv."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"577","DOI":"10.1161\/CIRCULATIONAHA.108.847772","article-title":"Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis","volume":"120","author":"Weidemann","year":"2009","journal-title":"Circulation"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1016\/j.jcmg.2018.11.005","article-title":"Distribution and prognostic significance of left ventricular global longitudinal strain in asymptomatic significant aortic stenosis: An individual participant data meta-analysis","volume":"12","author":"Magne","year":"2019","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1016\/j.jcmg.2018.08.040","article-title":"Assessment of subclinical left ventricular dysfunction in aortic stenosis","volume":"12","author":"Dahl","year":"2019","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"e009958","DOI":"10.1161\/CIRCIMAGING.119.009958","article-title":"Left ventricular global longitudinal strain is associated with long-term outcomes in moderate aortic stenosis","volume":"13","author":"Zhu","year":"2020","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"525","DOI":"10.1016\/j.jcmg.2020.09.031","article-title":"Structural and functional correlates of gradient-area patterns in severe aortic stenosis and normal ejection fraction","volume":"14","author":"Slimani","year":"2021","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"2447","DOI":"10.1016\/j.jacc.2016.02.070","article-title":"Paradoxical low-gradient aortic stenosis: The HFpEF of aortic stenosis","volume":"67","author":"Chin","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1542","DOI":"10.1093\/eurheartj\/ehr084","article-title":"Alterations in multidirectional myocardial functions in patients with aortic stenosis and preserved ejection fraction: A two-dimensional speckle tracking analysis","volume":"32","author":"Ng","year":"2011","journal-title":"Eur. Heart J."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1111\/echo.13407","article-title":"Increased valvulo-arterial impedance differently impacts left ventricular longitudinal, circumferential, and radial function in patients with aortic stenosis: A speckle tracking echocardiography study","volume":"34","author":"Galli","year":"2017","journal-title":"Echocardiography"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1111\/j.0742-2822.2004.t01-10-20040211.x","article-title":"Left ventricular midwall fractional shortening: Its relationship with the diastolic function analyzed by doppler echocardiography and tissue doppler in hypertensive patients","volume":"21","author":"Alvarez","year":"2004","journal-title":"Echocardiography"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1016\/j.jcmg.2012.10.015","article-title":"Stress echocardiography to assess stenosis severity and predict outcome in patients with paradoxical low-flow, low-gradient aortic stenosis and preserved LVEF","volume":"6","author":"Clavel","year":"2013","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"e006690","DOI":"10.1161\/CIRCIMAGING.117.006690","article-title":"Preload stress echocardiography predicts outcomes in patients with preserved ejection fraction and low-gradient aortic stenosis","volume":"10","author":"Kusunose","year":"2017","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"e007035","DOI":"10.1161\/CIRCIMAGING.117.007035","article-title":"Preload stress echocardiography: A new tool to confirm severity of low-gradient aortic stenosis","volume":"10","author":"Pibarot","year":"2017","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"e024505","DOI":"10.1161\/JAHA.121.024505","article-title":"Global longitudinal strain is incremental to left ventricular ejection fraction for the prediction of outcome in optimally treated dilated cardiomyopathy patients","volume":"11","author":"Raafs","year":"2022","journal-title":"J. Am. Heart Assoc."},{"key":"ref_50","first-page":"28","article-title":"Value of combined circumferential and longitudinal left ventricular systolic dysfunction to predict adverse outcome in patients with asymptomatic aortic stenosis","volume":"25","author":"Cioffi","year":"2016","journal-title":"J. Heart Valve Dis."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1111\/echo.14916","article-title":"Prognostic impact of impaired left ventricular midwall function during progression of aortic stenosis","volume":"38","author":"Cramariuc","year":"2021","journal-title":"Echocardiography"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1271","DOI":"10.1016\/j.jacc.2011.03.064","article-title":"Midwall fibrosis is an independent predictor of mortality in patients with aortic stenosis","volume":"58","author":"Dweck","year":"2011","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1755","DOI":"10.1016\/j.jacc.2017.01.034","article-title":"Midwall fibrosis and 5-year outcome in moderate and severe aortic stenosis","volume":"69","author":"Vassiliou","year":"2017","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"e007451","DOI":"10.1161\/CIRCIMAGING.117.007451","article-title":"Progression of hypertrophy and myocardial fibrosis in aortic stenosis: A multicenter cardiac magnetic resonance study","volume":"11","author":"Everett","year":"2018","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"414","DOI":"10.1152\/advan.00043.2020","article-title":"Understanding preload and preload reserve within the conceptual framework of a limited range of possible left ventricular end-diastolic volumes","volume":"44","author":"Peverill","year":"2020","journal-title":"Adv. Physiol. Educ."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/10\/2873\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T23:14:49Z","timestamp":1760138089000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/10\/2873"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,5,19]]},"references-count":55,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2022,5]]}},"alternative-id":["jcm11102873"],"URL":"https:\/\/doi.org\/10.3390\/jcm11102873","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2022,5,19]]}}}