Hemodynamics of paradoxical severe aortic stenosis: insight from a pressure–volume loop analysis

  • Michael GotzmannEmail author
  • Sabine Hauptmann
  • Maximilian Hogeweg
  • Dinah S. Choudhury
  • Fabian Schiedat
  • Johannes W. Dietrich
  • Timm H. Westhoff
  • Martin Bergbauer
  • Andreas Mügge
Original Paper



Controversy exists about the pathophysiology of different hemodynamic subgroups of AS. In particular, the mechanism of the paradoxical low-flow, low-gradient (PLFLG) AS with preserved ejection fraction (EF) is unclear.


A total of 41 patients with severe, symptomatic AS were divided into the following 4 subgroups based on the echocardiographically determined hemodynamics: (1) normal-flow, high-gradient (NFHG) AS; (2) low-flow, high-gradient AS; (3) paradoxical low-flow, low-gradient (PLFLG) AS with preserved EF and (4) low-flow, low-gradient (LFLG) AS with reduced EF. As part of the comprehensive invasive examinations, the analyses of the PV loops were performed with the IntraCardiac Analyzer (CD-Leycom, The Netherlands).


PLFLG was characterized by small left ventricular volumes as well as a decreased cardiac index, a decreased systolic contractility and a lower stroke work, than the conventional NFHG AS. Alterations in effective arterial elastance (2.36 ± 0.67 mmHg/ml in NFHG versus 3.01 ± 0.79 mmHg/ml in PLFLG, p = 0.036) and end-systolic elastance (3.72 ± 1.84 mmHg/ml in NFHG versus 5.53 ± 2.3 mmHg/ml in PLFLG, p = 0.040) indicated impaired vascular function and increased chamber stiffness.


The present study suggests that the hemodynamics of PLFLG AS can be explained by two mechanisms: (1) stiffness of the small left ventricle with reduced contractility, and (2) increased afterload due to the impairment of vascular function. Both mechanisms have similarities to those of heart failure with preserved EF. This type of remodeling may explain the poor prognosis of PLFLG AS.


Aortic stenosis Pressure–volume  loops Hemodynamics 



Aortic valve stenosis


Aortic valve area


B-type natriuretic peptide


Ejection fraction


Heart failure with preserved ejection fraction


Low-flow, high-gradient


Normal-flow, high-gradient


Paradoxical low-flow, low-gradient


Stroke volume index


Relaxation time constant



This work was supported by the German Heart Foundation/German Foundation of Heart Research (F/32/12).

Supplementary material

392_2019_1423_MOESM1_ESM.docx (12 kb)
Supplementary material 1 (DOCX 12 KB)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Michael Gotzmann
    • 1
    Email author
  • Sabine Hauptmann
    • 2
  • Maximilian Hogeweg
    • 1
  • Dinah S. Choudhury
    • 2
  • Fabian Schiedat
    • 3
  • Johannes W. Dietrich
    • 4
  • Timm H. Westhoff
    • 5
  • Martin Bergbauer
    • 2
  • Andreas Mügge
    • 1
  1. 1.Cardiovascular Center, St. Josef Hospital BochumRuhr-University BochumBochumGermany
  2. 2.Department of Cardiology, Marien Hospital WittenRuhr University BochumWittenGermany
  3. 3.Cardiology and AngiologyBergmannsheil, Ruhr University BochumBochumGermany
  4. 4.Department of Internal MedicineBergmannsheil, Ruhr University BochumBochumGermany
  5. 5.Medical Department IUniversity Hospital Marien Hospital Herne, Ruhr-University BochumHerneGermany

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