n engl j med wwwnejmorgmay - PDF document

n engl j med www.nejm.orgmay perspective aortic stenosis is associated with a high mortalityformed. There is an especially high risk of deaththe functional state of the left ventricle; in addition,condition stabilized. It is possible to pursue bothof these goals simultaneously with echocardio-derstanding of the pathophysiology of heart failuretolic pressures while maintaining normal systoliction. If, however, the hypertrophic remodeling iscess results in a decline in the ejection fraction. Aor-area is constant (or nearly constant) and is propor-volume declines, as it does in some patients withthere is a proportional decline in the pressure gra-presence of severe aortic stenosis, despite a low tients with Aortic Stenosis and a Low Transvalvular Pressure Gradient. DiagnosisTrue aorticYesABCNPDBNPDBNP Downloaded from www.nejm.org by GEOFFREY K. LIGHTHALL MD on May 06, 2003.For personal use only. No other uses without permission. All rights reserved. n engl j med www.nejm.orgmay of dobutamine or nitroprusside produces an in-true stenosis have a salutary response to aortic-valveHowever, not all patients with a low pressurecreased contractility. It is difficult to differentiaterelative aortic stenosis, because low-flow states lim-der these circumstances that selecte

d pharmaco-The administration of dobutamine or nitroprussideclear that the response to dobutamine or nitroprus-medical therapy. Given the rapid advances in surgerygeneral, however, although optimal treat-ment remains uncertain, treatment of relative aorticstenosis should be focused on medical therapy.to dobutamine valve disease itself does not contribute substantial-is directed at the cardiomyopathic failing ventricle.performed as soon as the patient is medically sta-of diuretics and may, in selected cases, require theuse of a positive inotropic agent or a vasodilator.Vasodilaincreased total vascular resistance act in concert toresistance. They found a substantial increase in car-to aortic-valve replacement. However, the patientscare unit. There are substantial risks associated withdicious use of From the Cardiology Division, Department of Medicine, GazesCardiac Research Institute, Medical University of South Carolina,and the Ralph H. Johnson Department of Veterans Affairs MedicalCenter „ both in Charleston, S.C. (M.R.Z.); and the Department ofCardiovascular Medicine, Lahey Clinic, Burlington, Mass. (W.H.G.). Downloaded from www.nejm.org by GEOFFREY K. LIGHTHALL MD on May 06, 2003.For personal use only. No other uses without permission. All rights reserved