Response to Letters Regarding Article, “Systemic Hypertension in Low-Gradient Severe Aortic Stenosis With Preserved Ejection Fraction”
We were delighted to read the letter by Dr Laskey emphasizing previous seminal investigations that helped establish the relationship between the systemic circulation and aortic valve hemodynamics, complementing our recent study of patients with systemic hypertension and low-gradient severe aortic stenosis with preserved ejection fraction.1 Indeed, Dr Laskey and colleagues helped shape the understanding that even in the presence of aortic valve stenosis, transvalvular pressure and flow are highly dependent on the resistive and capacitive properties of the arterial circulation.2 We also thank Dr Laskey for highlighting the influence of pressure recovery in patients with aortic valve stenosis. Close attention was paid to the assessment of aortic pressure at the most proximal location to the aortic valve during our hemodynamic evaluation of the patients in our study to minimize the potential for underestimation of the aortic valve gradient.
We thank Drs Dumesnil and Pibarot for their valuable letter highlighting the importance of considering the systemic arterial compliance, vascular resistance, and valvuloarterial impedance (Zva) in the assessment of patients with aortic valve stenosis. In several key investigations Drs Dumesnil and Pibarot have clearly shown the contribution of reduced systemic arterial compliance to the hemodynamics observed in patients with aortic stenosis and the prognostic impact of Zva.3,4 We fully agree that these tools are additive in the assessment of aortic stenosis and should be used. However, the present investigation focuses on the effects of uncontrolled systemic hypertension on hemodynamics in patients with low-gradient severe aortic stenosis with preserved ejection fraction. When a patient with symptomatic aortic stenosis with small valve area and low gradient presents with uncontrolled hypertension, we recommend treatment of hypertension, followed by reassessment of the aortic stenosis after the blood pressure is controlled. In the majority of patients in our study, the severity of aortic stenosis was only moderate after hemodynamic alterations produced by nitroprusside. As evidenced by the dramatic improvement in cardiac output, left ventricular filling pressure, and pulmonary artery pressure with nitroprusside afterload reduction in our study, symptoms in such patients may improve after treatment of the blood pressure alone.
Mackram F. Eleid, MD
Rick A. Nishimura, MD
Paul Sorajja, MD
Barry A. Borlaug, MD
Division of Cardiovascular Diseases
Mayo Clinic College of Medicine
- © 2014 American Heart Association, Inc.
- Eleid MF,
- Nishimura RA,
- Sorajja P,
- Borlaug BA
- Laskey WK,
- Kussmaul WG,
- Noordergraaf A