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Abstract
Valvular aortic stenosis associated to severe LV systolic dysfunction and a low pressure gradient is an infrequent but particularly challenging situation. Because the prognosis of low-flow AS under medical treatment is dismal, surgery may be recommended in most patients. Associated comorbidity, patient’s preferences, and local institution surgical results should definitely take as strong determinants of the final decision. If cardiac surgery is being performed for associated valvular or ischemic heart disease, the patient has severe LV dysfunction, and aortic valve area is ≤ 1 cm2, aortic replacement should always be performed.
Preoperative dobutamine stress testing may help to assess surgical risk, but there is no strong scientific evidence to deny surgery based exclusively on the results of this test. If LV contractile reserve is identified, valve replacement must be encouraged. However, if contractile reserve is absent there is still a potential benefit for surgery. Although perioperative mortality is very high in patients without contractile reserve, valve replacement improves prognosis in these patients if cardiac transplantation is not an option.