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Outcome After Aortic Valve Replacement for Low-Flow/Low-Gradient Aortic Stenosis with Poor Contractile Reserve on Dobutamine Stress Echocardiography
Sanjay Kumar1, Tarun K. Lahiri2.
1Division of Cardiac Surgery, Department of Surgery,Yale university school of Medicine, New Haven, CT, USA, 2Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.

OBJECTIVE: Few data are available on risk stratification for valve replacement in patients with AS, LV dysfunction and low transvalvular gradients. We assessed risk stratification by using dobutamine stress echocardiography (DSE) in patients with aortic stenosis (AS) and severe left ventricular (LV) dysfunction.
METHODS: Low-dose DSE was performed in 10 patients (3 woman and 7 men; median [quartile range] age in years: 47 [32 to 78]; left ventricular ejection fraction: 0.29 [0.23 to 0.32]; aortic valve area [cm2]: 0.7 [0.5 to 0.8]; mean transaortic gradient [mm Hg]: 26 [21 to 33]). Patients were classified into two groups: group I (n = 6, LV contractile reserve on DSE) and group II (n = 4, poor contractile reserve). Valve replacement was performed in 6 and 3 patients in groups I and II, respectively.
RESULTS: Perioperative mortality was 0% in group I and 0% in group II. Survival at 2 years after the operation was 100% in group I. The effect of valve surgery on survival remained significant in both groups after adjustment for age, diabetes, respiratory disease and hypertension. Medical therapy had the same effect in both groups.
CONCLUSIONS: In patients with AS, LV dysfunction and low transvalvular gradients, contractile reserve on DSE is associated with a low operative risk and good long-term prognosis after valve surgery. In contrast, operative mortality may be high in the absence of contractile reserve. Light premedication, Thermodilution cardiac output pulmonary artery catheters, and Omniplanar transesophageal echocardiography (TEE) remains essential armamentariums for perioperative anaesthetic managements in this high risk group of the patients.

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