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Precisão da área valvula aórtica projetada em doentes com estenose aórtica de baixo fluxo-baixo gradiente: revisão sistemática
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Introdução: Um grande desafio da estenose aórtica (EAo) é a diferenciação entre a EAo grave “verdadeira” e a pseudo-estenose em doentes com baixo fluxo e baixo gradiente. Vários critérios foram propostos para diferenciar estes dois subgrupos, no entanto as alterações no gradiente médio (GM) e na área valvular durante o ecocardiograma de stress com dobutamina (ESD) dependem da magnitude do aumento de fluxo. Para ultrapassar esta limitação, foi proposto estimar área da válvula aórtica (AVA) para um fluxo transvalvular normalizado.
Objetivo: Avaliar a acurácia e validade da utilização da área valvular aórtica projetada (AVAproj) como ferramenta para diferenciar entre EAo grave “verdadeira” e pseudoestenose durante o ESD.
Metodologia: Foi realizada uma pesquisa de literatura usando as seguintes palavras-chave, assim como associações entre elas: projected aortic valve area, aortic stenosis, flow rate, stress echocardiography, dobutamine stress echocardiography, low-gradient severe aortic stenosis, stroke volume index, transvalvular flow rate, low flow-low gradient aortic stenosis, procurando todos os estudos randomizados e não randomizados sobre o uso da AVAproj.
Resultados: A pesquisa resultou na seleção de 4 estudos observacionais publicados entre 2006 e 2018 com um total de 429 doentes com EAo grave ou pseudo-grave. Foi notada uma grande variabilidade metodológica e estatística dos estudos pelo que não foi possível fazer uma meta-análise dos dados. Apesar da grande heterogeneidade, o global dos dados sugere que a AVAproj apresenta os melhores valores de sensibilidade, especificidade e percentagem correta de classificação, permitindo reclassificar em média 9 em cada 10 doentes.
Conclusão: O cálculo da AVAproj poderá ajudar na reclassificação e tomada de decisão clínica nos doentes com gravidade da EAo dúbia.
Introduction: A major challenge in aortic stenosis (AS) is the differentiation between “true” severe AS and pseudo-stenosis in patients with low flow and low gradient. Different criteria have been proposed to differentiate between these two subgroups, however the changes in mean gradient and valvular area during dobutamine stress echocardiography (DSE) depend on the magnitude of the increase in flow. To overcome this limitation, it has been proposed to estimate aortic valve area (AVA) for normalized transvalvular flow. Objective: To evaluate the accuracy and validity of using the projected aortic valve area (AVAproj) as a tool to differentiate between “true” severe AS and pseudo-stenosis during DSE. Methods: A literature search was carried out using the following keywords, as well as associations between them: “projected aortic valve area”, “aortic stenosis”, “flow rate”, “stress echocardiography”, “dobutamine stress echocardiography”, “low-gradient severe aortic stenosis”, “stroke volume index”, “transvalvular flow rate”, “low flow-low gradient aortic stenosis”, looking for all randomized and non-randomized studies on the use of AVAproj. Results: The search resulted in the selection of 4 observational studies published between 2006 and 2018 with a total of 429 patients with severe or pseudo-severe AS. There was great methodological and statistical variability in the studies, so it was not possible to carry out a meta-analysis of the data. Despite the great heterogeneity, the overall data suggests that the AVAproj has the best values for sensitivity, specificity and percentage of correct classification, allowing an average of 9 out of 10 patients to be reclassified. Conclusion: The calculation of the AVAproj could help with reclassification and clinical decision-making in patients with dubious AS severity.
Introduction: A major challenge in aortic stenosis (AS) is the differentiation between “true” severe AS and pseudo-stenosis in patients with low flow and low gradient. Different criteria have been proposed to differentiate between these two subgroups, however the changes in mean gradient and valvular area during dobutamine stress echocardiography (DSE) depend on the magnitude of the increase in flow. To overcome this limitation, it has been proposed to estimate aortic valve area (AVA) for normalized transvalvular flow. Objective: To evaluate the accuracy and validity of using the projected aortic valve area (AVAproj) as a tool to differentiate between “true” severe AS and pseudo-stenosis during DSE. Methods: A literature search was carried out using the following keywords, as well as associations between them: “projected aortic valve area”, “aortic stenosis”, “flow rate”, “stress echocardiography”, “dobutamine stress echocardiography”, “low-gradient severe aortic stenosis”, “stroke volume index”, “transvalvular flow rate”, “low flow-low gradient aortic stenosis”, looking for all randomized and non-randomized studies on the use of AVAproj. Results: The search resulted in the selection of 4 observational studies published between 2006 and 2018 with a total of 429 patients with severe or pseudo-severe AS. There was great methodological and statistical variability in the studies, so it was not possible to carry out a meta-analysis of the data. Despite the great heterogeneity, the overall data suggests that the AVAproj has the best values for sensitivity, specificity and percentage of correct classification, allowing an average of 9 out of 10 patients to be reclassified. Conclusion: The calculation of the AVAproj could help with reclassification and clinical decision-making in patients with dubious AS severity.
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estenose aórtica baixo fluxo-baixo gradiente ecocardiografia de stress com dobutamina área valvular aórtica área valvular aórtica projetada aortic stenosis low flow-low gradient dobutamine stress echocardiography aortic valve area projected aortic valve area