Paradoxical low-flow aortic stenosis is defined by increased ventricular hydraulic load and reduced longitudinal strain.

Aims Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. This study investigates the relationship of systolic loading and strain to PLF-AS to further define its pathophysiology. Methods One hundred and twenty patients (age 79 +/- 12years, 37% men) with an indexed aortic valve area (AVAi) of 0.6cm(2)/m(2) or less and an ejection fraction of 50% or higher were divided into two groups based on indexed stroke volume (SVi): PLF-AS, SVi <= 35ml/m(2), N=46; normal-flow aortic stenosis, SVi > 35ml/m(2), N=74). Valvular and arterial load were assessed using multiple measurements, and strain was assessed using speckle-tracking echocardiography. Results Patients with PLF-AS were found to have more valvular load (lower AVAi, P=0.028; lower energy loss coefficient, P=0.001), more arterial load [decreased arterial compliance and increased systemic vascular resistance (SVR), both P<0.001] and more total hydraulic load [increased valvuloarterial impedance (Zva), P<0.001]. Transvalvular gradients and arterial pressures were similar. Longitudinal strain was lower in PLF-AS (P<0.001), but circumferential and rotation strains were similar. On adjusted regression, AVAi, SVR and longitudinal strain were associated with PLF-AS [odds ratio (OR)=1.34, P=0.043; OR=1.31, P=0.004; OR=1.34, P=0.011, respectively]. When SVR and AVAi were replaced with Zva, longitudinal strain and Zva (OR=1.38, P=0.015; OR=1.33, P<0.001 for both, respectively) were associated with PLF-AS. Conclusion Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.