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Impact of stroke volume assessment by three-dimensional transesophageal echocardiography on the classification of low-gradient aortic stenosis

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Abstract

Background

Accurate assessment of flow status is crucial in low-gradient aortic stenosis (AS). However, the clinical implication of three-dimensional transesophageal echocardiography (3DTEE) on flow status evaluation remains unclear. This study aimed to investigate the assessment of flow status using 3D TEE in low-gradient AS patients.

Methods

We retrospectively reviewed patients diagnosed with low-gradient AS and preserved ejection fraction at our institution between 2019 and 2022. Patients were categorized into low-flow/low-gradient (LF-LG) AS or normal-flow/low-gradient (NF-LG) AS based on two-dimensional transthoracic echocardiography (2DTTE). We compared the left ventricular outflow tract (LVOT) geometry between the two groups and reclassified them using stroke volume index (SVi) obtained by 3DTEE.

Results

Among 173 patients (105 with LF-LG AS and 68 with NF-LG AS), 54 propensity-matched pairs of patients were analyzed. 3DTEE-derived ellipticity index of LVOT was significantly higher in LF-LG AS patients compared to NF-LG AS patients (p = 0.012). We assessed the discordance in flow status classification between SVi2DTTE and SVi3DTEE in both groups using a cutoff value of 35 ml/m2. The LF-LG AS group exhibited a significantly higher discordance rate compared to the NF-LG AS group, with rates of 50% and 2%, respectively. The optimal cutoff values of SVi3DTEE for identifying low flow status, based on 2DTTE-derived cutoff values, were determined to be 43 ml/m2.

Conclusions

LVOT ellipticity in low-gradient AS patients varies depending on flow status, and this difference contributes to discrepancies between SVi3DTEE and SVi2DTTE, particularly in LF-LG AS patients. Utilizing SVi3DTEE is valuable for accurately assessing flow status.

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Cedars-Sinai Medical Center, Smidt Heart Institute, Beverly Blvd, Los Angeles, CA, 8700, USA

    Nobuichiro Yagi, Mana Ogawa, Ken Kuwajima, Hiroko Hasegawa, Takafumi Yamane & Takahiro Shiota

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  1. Nobuichiro Yagi
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  2. Mana Ogawa
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  3. Ken Kuwajima
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  4. Hiroko Hasegawa
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  5. Takafumi Yamane
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  6. Takahiro Shiota
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Contributions

NY: conceptualization, methodology, investigation, validation, formal analysis, data curation, visualization, writing—original draft. MO: investigation, validation, data curation, writing—review & editing. KK: data curation, writing—review & editing. HH: data curation, writing—review & editing. TY: data curation, writing—review & editing. TS: conceptualization, methodology, resources, supervision, project administration, writing—review & editing.

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Correspondence to Nobuichiro Yagi.

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Supplementary Information

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12574_2023_638_MOESM1_ESM.tif

Supplemental Figure 1. Comparisons of LVOT areas between 2D TTE and 3D TEE. Comparisons of LVOT areas between 2D TTE and 3D TEE are depicted in Panel A and C for patients with LF-LG AS, and in Panel B and D for patients with NF-LG AS. LVOT areas were compared using linear regression (Panels A and B) and Bland-Altman analysis (Panels C and D). LF-LG AS, low-flow/low-gradient aortic stenosis; LVOT, left ventricular outflow tract; NF-LG AS, normal-flow/low-gradient aortic stenosis; 3D TEE, three-dimensional transesophageal echocardiography; 2D TTE, two-dimensional transthoracic echocardiography. (TIF 5616 KB)

12574_2023_638_MOESM2_ESM.tif

Supplemental Figure 2. Comparisons of LVOT areas between 2D TTE and MDCT. Comparisons of LVOT areas between 2D TTE and MDCT are depicted in Panel A and C for patients with LF-LG AS, and in Panel B and D for patients with NF-LG AS. LVOT areas were compared using linear regression (Panels A and B) and Bland-Altman analysis (Panels C and D). LF-LG AS, low-flow/low-gradient aortic stenosis; LVOT, left ventricular outflow tract; MDCT, multidetector computed tomography; NF-LG AS, normal-flow/low-gradient aortic stenosis; 2D TTE, two-dimensional transthoracic echocardiography. (TIF 5530 KB)

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Yagi, N., Ogawa, M., Kuwajima, K. et al. Impact of stroke volume assessment by three-dimensional transesophageal echocardiography on the classification of low-gradient aortic stenosis. J Echocardiogr (2024). https://doi.org/10.1007/s12574-023-00638-4

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  • DOI: https://doi.org/10.1007/s12574-023-00638-4

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