Progression of ascending aortopathy may not occur after transcatheter aortic valve replacement in severe bicuspid aortic stenosis

Background/Aims@#We evaluated changes in the ascending aorta dimension post-transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BiAV) and tricuspid aortic valve (TAV) patients. @*Methods@#Patients with severe aortic stenosis undergoing TAVR at Seoul National University Hospital were consecutively recruited. Patients with less than 12 months’ follow-up and/or with an ascending aorta size larger than 50 mm were excluded. The ascending aorta size was measured on a parasternal long axis view using transthoracic echocardiography. @*Results@#Among the 67 patients who were included (age: 76.5 ± 6.5 years; male: 52.2%; AV area: 0.67 ± 0.15 cm2), 19 (28.4%) had BiAV; 48 (71.6%) had TAV. The median (interquartile ranges) follow-up duration was 398 days (361 to 451). BiAV patients were younger (73.2 ± 7.2 vs. 77.8 ± 5.8, p = 0.008), and had lower incidences of chronic renal disease (5.3% vs. 35.4%, p = 0.014) and history of coronary intervention (15.8% vs. 50.0%, p = 0.013), than TAV patients. On pre-procedural echocardiography, the ascending aorta dimensions in BiAV patients were larger than those in TAV patients (40.5 ± 3.8 mm vs. 35.9 ± 4.2 mm, p < 0.005). The ascending aorta dimension changed minimally during follow-up; post-TAVR, the ascending aorta’s growth rate was –0.11 ± 1.9 and 0.26 ± 1.8 mm/yr in patients with BiAV and TAV, respectively (p = 0.50). Progression of the ascending aorta’s dimension postTAVR was not clinically significant in BiAV patients. @*Conclusions@#The concern about the progression of aortopathy in BiAV patients post-TAVR may not be a clinical issue. This should be confirmed in studies with a larger population and with a longer follow-up duration.

Early Surgery versus Watchful Waiting in Patients with Moderate Aortic Stenosis and Left Ventricular Systolic Dysfunction

Background and Objectives@#Severe aortic stenosis (AS) with left ventricular systolic dysfunction (LVSD) is a class I indication for aortic valve replacement (AVR) but this recommendation is not well established in those at the stage of moderate AS. We investigate the clinical impact of AVR among patients with moderate AS and LVSD. @*Methods@#From 2001 to 2017, we consecutively identified patients with moderate AS and LVSD, defined as aortic valve area 1.0–1.5 cm2 and left ventricular ejection fraction <50%. The primary outcome was all-cause death. The outcomes were compared between those who underwent early surgical AVR (within 2 years of index echocardiography) at the stage of moderate AS versus those who were followed medically without AVR at the outpatient clinic. @*Results@#Among 255 patients (70.1±11.3 years, male 62%), 37 patients received early AVR. The early AVR group was younger than the medical observation group (63.1±7.9 vs. 71.3±11.4) with a lower prevalence of hypertension and chronic kidney disease. During a median 1.8-year follow up, 121 patients (47.5%) died, and the early AVR group showed a significantly lower all-cause death rate than the medical observation group (5.03PY vs. 18.80PY, p<0.001). After multivariable Cox-proportional hazard regression adjusting for age, sex, comorbidities, and laboratory data, early AVR at the stage of moderate AS significantly reduced the risk of death (hazard ratio, 0.43; 95% confidence interval 0.20–0.91; p=0.028). @*Conclusions@#In patients with moderate AS and LVSD, AVR reduces the risk of all-cause death. A prospective randomized trial is warranted to confirm our findings.

Fabry Disease that Phenocopies Hypertrophic Cardiomyopathy: a thorough Genetic ‘Detective’ Identifies the ‘Rogue’ Hidden in the GLA Gene

No abstract available.

Coronary Computed Tomography Angiography for the Diagnosis of Vasospastic Angina: Comparison with Invasive Coronary Angiography and Ergonovine Provocation Test

OBJECTIVE: To investigate the diagnostic validity of coronary computed tomography angiography (cCTA) in vasospastic angina (VA) and factors associated with discrepant results between invasive coronary angiography with the ergonovine provocation test (iCAG-EPT) and cCTA. MATERIALS AND METHODS: Of the 1397 patients diagnosed with VA from 2006 to 2016, 33 patients (75 lesions) with available cCTA data from within 6 months before iCAG-EPT were included. The severity of spasm (% diameter stenosis [%DS]) on iCAG-EPT and cCTA was assessed, and the difference in %DS (Δ%DS) was calculated. Δ%DS was compared after classifying the lesions according to pre-cCTA-administered sublingual nitroglycerin (SL-NG) or beta-blockers. The lesions were further categorized with %DS ≥ 50% on iCAG-EPT or cCTA defined as a significant spasm, and the diagnostic performance of cCTA on identifying significant spasm relative to iCAG-EPT was assessed. RESULTS: Compared to lesions without SL-NG treatment, those with SL-NG treatment showed a higher Δ%DS (39.2% vs. 22.1%, p = 0.002). However, there was no difference in Δ%DS with or without beta-blocker treatment (35.1% vs. 32.6%, p = 0.643). The significant difference in Δ%DS associated with SL-NG was more prominent in patients who were aged < 60 years, were male, had body mass index < 25 kg/m2, and had no history of hypertension, diabetes, or dyslipidemia. Based on iCAG-EPT as the reference, the per-lesion-based sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cCTA for VA diagnosis were 7.5%, 94.0%, 60.0%, 47.1%, and 48.0%, respectively. CONCLUSION: For patients with clinically suspected VA, confirmation with iCAG-EPT needs to be considered without completely excluding the diagnosis of VA simply based on cCTA results, although further prospective studies are required for confirmation.

Hemodynamic and Histopathologic Benefits of Early Treatment with Macitentan in a Rat Model of Pulmonary Arterial Hypertension

BACKGROUND AND OBJECTIVES@#Macitentan (MAC) reduces morbidity and mortality among advanced-stage pulmonary arterial hypertension (PAH) patients. However, data regarding the histopathologic and hemodynamic benefits of MAC treatment at an early stage of PAH is lacking.@*METHODS@#One week after monocrotaline (MCT) injection, rats were randomly assigned to MAC (n=16), MAC combined with sildenafil (SIL) (MAC+SIL, n=16), or normal saline (MCT, n=16). Twelve sham rats (Sham) were included for comparison. Right ventricular (RV) systolic function was assessed via echocardiography as the RV fractional area change (RV-FAC). An invasive pressure-volume analysis using a Millar conductance catheter was performed 7 weeks after MCT injection. Rats were subsequently euthanized for histopathologic analysis.@*RESULTS@#RV-right atrial pressure gradient on echocardiography was significantly increased 3 weeks after MCT injection, but was maintained in the Sham. RV-FAC was less deteriorated in the MAC, compared to that in the MCT (44±3% vs. 25±7%, p 0.05 vs. the MAC). On invasive hemodynamic analyses, RV end-systolic (196±78 µL) and end-diastolic volumes (310±86 µL), pulmonary artery systolic pressure (89±7.2 mmHg), and end-systolic pressure-volume relationship (−254±25.1) were significantly worse in the MCT vs. in the MAC (101±45 µL, 235±55 µL, 40±10.5 mmHg, and −145±42.1, respectively) and MAC+SIL (109±47 µL, 242±46 µL, 38±9.2 mmHg, and −151±39.2, respectively) (all p 0.05). On histopathology, both RV and lung fibrosis were significantly reduced in the MAC and MAC+SIL vs. in the MCT (all p < 0.05); the 2 treatment groups did not differ.@*CONCLUSIONS@#MAC treatment at an earlier stage significantly attenuated experimental PAH progression hemodynamically and histopathologically.

Clinical Characteristics of Korean Patients with Bicuspid Aortic Valve Who Underwent Aortic Valve Surgery

BACKGROUND AND OBJECTIVES@#Clinical data for Korean patients with bicuspid aortic valve (BAV) that underwent aortic valve (AV) surgery are currently limited.@*METHODS@#Data for 1,160 consecutive adult BAV patients who underwent AV surgery from 2000 to 2014 in 4 tertiary referral centers were retrospectively analyzed. A standard case report form was used for clinical and echocardiographic parameters.@*RESULTS@#Mean age at the time of AV surgery was 59±13 years. The most common cause of AV surgery was aortic stenosis (AS, 892 [77%]), followed by aortic regurgitation (AR, 199 [17%]), and infective endocarditis (69 [6%]). AS showed a skewed peak in the aged population and was the predominant cause of AV surgery (87%) in patients ≥50 years of age, whereas AR (46%) and active infective endocarditis (19%) were more common in younger patients (p < 0.001). Echocardiographic determination of the BAV phenotype revealed that fusion of the right coronary cusp (RCC) and left coronary cusp (LCC) was most common (622 [53%]), followed by fusion of RCC and non-coronary cusp (NCC) (313 [27%]), and fusion of LCC and NCC (42 [4%]); the BAV phenotype could not be determined in the remaining 183 patients (16%). Fusion of RCC and LCC was more commonly observed in patients with AR than in those with AS (74% vs. 49%; p < 0.001).@*CONCLUSION@#BAV patients were characterized by distinct surgical indications according to their age. Possible associations between BAV phenotypes and surgical indications with potential impacts of ethnicity need to be tested in further studies.

Hemodynamic and Histopathologic Benefits of Early Treatment with Macitentan in a Rat Model of Pulmonary Arterial Hypertension

BACKGROUND AND OBJECTIVES: Macitentan (MAC) reduces morbidity and mortality among advanced-stage pulmonary arterial hypertension (PAH) patients. However, data regarding the histopathologic and hemodynamic benefits of MAC treatment at an early stage of PAH is lacking. METHODS: One week after monocrotaline (MCT) injection, rats were randomly assigned to MAC (n=16), MAC combined with sildenafil (SIL) (MAC+SIL, n=16), or normal saline (MCT, n=16). Twelve sham rats (Sham) were included for comparison. Right ventricular (RV) systolic function was assessed via echocardiography as the RV fractional area change (RV-FAC). An invasive pressure-volume analysis using a Millar conductance catheter was performed 7 weeks after MCT injection. Rats were subsequently euthanized for histopathologic analysis. RESULTS: RV-right atrial pressure gradient on echocardiography was significantly increased 3 weeks after MCT injection, but was maintained in the Sham. RV-FAC was less deteriorated in the MAC, compared to that in the MCT (44±3% vs. 25±7%, p 0.05 vs. the MAC). On invasive hemodynamic analyses, RV end-systolic (196±78 µL) and end-diastolic volumes (310±86 µL), pulmonary artery systolic pressure (89±7.2 mmHg), and end-systolic pressure-volume relationship (−254±25.1) were significantly worse in the MCT vs. in the MAC (101±45 µL, 235±55 µL, 40±10.5 mmHg, and −145±42.1, respectively) and MAC+SIL (109±47 µL, 242±46 µL, 38±9.2 mmHg, and −151±39.2, respectively) (all p 0.05). On histopathology, both RV and lung fibrosis were significantly reduced in the MAC and MAC+SIL vs. in the MCT (all p < 0.05); the 2 treatment groups did not differ. CONCLUSIONS: MAC treatment at an earlier stage significantly attenuated experimental PAH progression hemodynamically and histopathologically.

Clinical Characteristics of Korean Patients with Bicuspid Aortic Valve Who Underwent Aortic Valve Surgery

BACKGROUND AND OBJECTIVES: Clinical data for Korean patients with bicuspid aortic valve (BAV) that underwent aortic valve (AV) surgery are currently limited. METHODS: Data for 1,160 consecutive adult BAV patients who underwent AV surgery from 2000 to 2014 in 4 tertiary referral centers were retrospectively analyzed. A standard case report form was used for clinical and echocardiographic parameters. RESULTS: Mean age at the time of AV surgery was 59±13 years. The most common cause of AV surgery was aortic stenosis (AS, 892 [77%]), followed by aortic regurgitation (AR, 199 [17%]), and infective endocarditis (69 [6%]). AS showed a skewed peak in the aged population and was the predominant cause of AV surgery (87%) in patients ≥50 years of age, whereas AR (46%) and active infective endocarditis (19%) were more common in younger patients (p < 0.001). Echocardiographic determination of the BAV phenotype revealed that fusion of the right coronary cusp (RCC) and left coronary cusp (LCC) was most common (622 [53%]), followed by fusion of RCC and non-coronary cusp (NCC) (313 [27%]), and fusion of LCC and NCC (42 [4%]); the BAV phenotype could not be determined in the remaining 183 patients (16%). Fusion of RCC and LCC was more commonly observed in patients with AR than in those with AS (74% vs. 49%; p < 0.001). CONCLUSION: BAV patients were characterized by distinct surgical indications according to their age. Possible associations between BAV phenotypes and surgical indications with potential impacts of ethnicity need to be tested in further studies.

Erratum: Cardiomyopathies with Mixed and Inapparent Morphological Features in Cardiac Troponin I3 Mutation

In the article, “Cardiomyopathies with Mixed and Inapparent Morphological Features in Cardiac Troponin I3 Mutation” in Volume 47(3), page 413-417, arrows in Fig. 5C were misplaced.

Cardiomyopathies with Mixed and Inapparent Morphological Features in Cardiac Troponin I3 Mutation

The fact that different types of cardiomyopathies can be manifested by the same sarcomere protein gene mutation in a single family is well known. However, mixed features of different types of cardiomyopathies in a single patient have not been well appreciated. We identified a novel mutation in cardiac troponin I3 (Arg186Gly) in the present case, and two of the family members showed mixed morphologic features of hypertrophic cardiomyopathy and left ventricular non-compaction. Moreover, both the features of cardiomyopathies were not apparent for each type of cardiomyopathy. In the patient's family, four other members had unexpected deaths before the age of 30.

Echocardiographic Predictors for Left Ventricular Remodeling after Acute ST Elevation Myocardial Infarction with Low Risk Group: Speckle Tracking Analysis

BACKGROUND: We sought to assess echocardiographic predictors of left ventricular (LV) adverse remodeling after successfully reperfused acute ST elevation myocardial infarction (STEMI). LV remodeling is commonly found in STEMI patients and it may suggest adverse outcome in acute myocardial infarction. We sought to identify whether 2D strain and torsion be independent parameters for prediction of LV adverse remodeling. METHODS: We investigated 208 patients with low-risk STEMI patients who had follow up echocardiography at 6 or more months. After clinical assessments, all patients received revascularization according to current guideline. LV remodeling was defined as > 20% increase in end-diastolic volume (EDV) at follow up. RESULTS: During the follow-up (11.9 ± 5.3 months), 53 patients (25.5%) showed LV remodeling. In univariate analysis, EDV, end-systolic volume, deceleration time (DT), CK-MB, and global longitudinal strain (GLS) were associated with LV remodeling. In multivariate analysis, EDV [hazard ratio (HR): 0.922, 95% confidence interval (CI): 0.897-0.948, p< 0.001], GLS (HR: 0.842, 95% CI: 0.728-0.974, p = 0.020), DT (HR: 0.989, 95% CI: 0.980-0.998, p = 0.023) and CK-MB (HR: 1.003, 95% CI: 1.000-1.005, p = 0.033) independently predicted LV remodeling. However, global circumferential strain, net twist, and twist or untwist rate were not associated with remodeling. CONCLUSION: Of various parameters of speckle strain, only GLS predicted adverse remodeling in STEMI patients.

Prognostic Value of Renal Function for Cardiac Events in Patients Without Significant Stenosis on Coronary Computed Tomography Angiography

This study was conducted to determine clinical parameters predicting future major adverse cardiovascular events (MACEs) in patients without significant stenosis on coronary computed tomographic angiography (CCTA). A total of 625 patients with suspected coronary artery disease (CAD) who underwent CCTA that revealed insignificant ( 90 days after CCTA) revascularization were assessed. During the mean follow-up period of 819 +/- 529 days (median 837 days), there were 28 cases of MACEs (4.5%). In multivariable Cox regression analysis, independent predictors for MACEs were male sex (hazard ratio [HR], 2.40; 95% confidence interval [CI], 1.01-5.69; P = 0.046) and low estimated creatinine clearance (eCCr) (< 60 mL/min/1.73 m2) (HR, 3.07; 95% CI, 1.22-7.74; P = 0.017). Low eCCr was the only independent predictor for hard events including cardiac death and MI (HR, 17.6, 95% CI, 1.44-215.7; P = 0.025). In conclusion, renal function is an independent predictor for cardiovascular events among patients without significant CAD by CCTA. Careful monitoring and preventive strategy are warranted in patients with impaired renal function even without significant CAD.

Effect of Dipeptidyl Peptidase-4 Inhibitor on All-Cause Mortality and Coronary Revascularization in Diabetic Patients

BACKGROUND: Anti-atherosclerotic effect of dipeptidyl peptidase-4 (DPP-4) inhibitors has been suggested from previous studies, and yet, its association with cardiovascular outcome has not been demonstrated. We aimed to evaluate the effect of DPP-4 inhibitors in reducing mortality and coronary revascularization, in association with baseline coronary computed tomography (CT). METHODS: The current study was performed as a multi-center, retrospective observational cohort study. All subjects with diabetes mellitus who had diagnostic CT during 2007-2011 were included, and 1866 DPP-4 inhibitor users and 5179 non-users were compared for outcome. The primary outcome was all-cause mortality and secondary outcome included any coronary revascularization therapy after 90 days of CT in addition to all-cause mortality. RESULTS: DPP-4 inhibitors users had significantly less adverse events [0.8% vs. 4.4% in users vs. non-users, adjusted hazard ratios (HR) 0.220, 95% confidence interval (CI) 0.102-0.474, p = 0.0001 for primary outcome, 4.1% vs. 7.6% in users vs. non-users, HR 0.517, 95% CI 0.363-0.735, p = 0.0002 for secondary outcome, adjusted variables were age, sex, presence of hypertension, high sensitivity C-reactive protein, glycated hemoglobin, statin use, coronary artery calcium score and degree of stenosis]. Interestingly, DPP-4 inhibitor seemed to be beneficial only in subjects without significant stenosis (adjusted HR 0.148, p = 0.0013 and adjusted HR 0.525, p = 0.0081 for primary and secondary outcome). CONCLUSION: DPP-4 inhibitor is associated with reduced all-cause mortality and coronary revascularization in diabetic patients. Such beneficial effect was significant only in those without significant coronary stenosis, which implies that DPP-4 inhibitor may have beneficial effect in earlier stage of atherosclerosis.

Left Atrial Intramural Hematoma after Removal of Atrial Myxoma: Cardiac Magnetic Resonance in the Differential Diagnosis of Intra-Cardiac Mass

Left atrial (LA) dissection is a rare entity, which is, in most cases, observed after valvular intervention. Transesophageal echocardiography (TEE) is considered to be a modality of choice in the diagnosis of LA dissection. However, LA dissection might be missed clinically in the absence of significant hemodynamic changes, and moreover physicians are occasionally reluctant to perform TEE due to its semi-invasiveness. Recently, cardiac magnetic resonance (CMR) has been introduced as a modality to perform different roles to existing imaging modalities, such as echocardiography. Given that CMR can provide information on tissue characteristics, it may give incremental information to TEE. We here present a rare case of LA dissection following LA myxoma removal, where CMR can make a correct diagnosis and guide management strategy.

Association of Myocardial Angiogenesis with Structural and Functional Ventricular Remodeling in Aortic Stenosis Patients with Normal Ejection Fraction

BACKGROUND: Although rarefaction of myocardial angiogenesis has been shown to be associated with left ventricular (LV) systolic dysfunction in animal models of ventricular hypertrophy, this relationship has not been investigated in depth nor validated in humans. We aimed to analyze the relationship of myocardial angiogenesis with various functional and structural ventricular remodeling parameters in moderate to severe aortic stenosis (AS) patients with normal LV ejection fraction (LVEF). METHODS: A total of 38 moderate or severe AS patients with LVEF > 50% were enrolled for the current study and all patients underwent LV endomyocardial biopsy at the septum during aortic valve replacement. The biopsy specimens were stained for platelet endothelial cell adhesion molecule-1 (CD31) to analyze the density of blood vessels in the myocardium. RESULTS: The degree of myocardial angiogenesis tended to increase with worse myocardial systolic function, LV filling pressure and progressed ventricular hypertrophy (Spearman's rho = -0.388, p = 0.016 for LVEF; Spearman's rho = 0.442, p = 0.007 for E/e'; Spearman's rho = 0.424, p = 0.008 for LV mass index). The degree of myocardial angiogenesis was also significantly associated with the degree of aortic valve stenosis (Spearman's rho = -0.368, p = 0.023). There was significant difference in the degree of myocardial angiogenesis according to the LV geometry (p = 0.016 for mean difference between different LV geometry groups by analysis of variance). Significant predictors of myocardial blood vessel density were LV mass index (beta = 0.398, p = 0.010) and LVEF (beta = -0.313, p = 0.028). CONCLUSION: There is a close relationship between myocardial angiogenesis and LV remodeling in moderate to severe AS patients with normal LVEF, with angiogenesis increasing with LV hypertrophy. Further studies to demonstrate the mechanism underlying this phenomenon is warranted.

Infective Endocarditis Associated with Transcatheter Aortic Valve Replacement: Potential Importance of Local Trauma for a Deadly Nidus

Recently, transcatheter aortic valve replacement (TAVR) has emerged as an alternative for the treatment of severe symptomatic aortic stenosis patients. Although experience with TAVR is increasing exponentially, few cases of post-TAVR endocarditis are reported. We present a case of 76-year-old man with infective endocarditis after TAVR who was definitely diagnosed by echocardiography.

Tricuspid Regurgitation: Clinical Importance and Its Optimal Surgical Timing

Tricuspid regurgitation (TR) has long been neglected based on the false belief that it is substantially rare in prevalence and is not so important in determining prognosis. Recent consecutive publications refuted this concept surrounding TR, and now we are contemplating this entity from different point of view. In this review, we mainly focus on isolated form of severe TR. In our daily clinical practice, however, patients with problems in more than one valve are more frequently encountered. Hence, we briefly touch on the results of severe TR surgery with or without left side valve operations here and there, as well.

Isolated, Broad-Based Apical Diverticulum: Cardiac Magnetic Resonance Is a "Terminator" of Cardiac Imaging Modality for the Evaluation of Cardiac Apex

In spite of the frequent involvement of many cardiac diseases, it is difficult to evaluate the left ventricular apex in detail with transthoracic echocardiography, a first-line imaging modality in cardiovascular diseases, because the apex is very closely located at the echocardiographic probe. Cardiac magnetic resonance enables us to evaluate the cardiac apex without any limitation to the image acquisition. We here present a case regarding a broad-based apical diverticulum, which was initially confused with apical aneurysm.

Incidence, Diagnosis and Prognosis of Cardiac Amyloidosis

BACKGROUND AND OBJECTIVES: Cardiac involvement is frequent in systemic amyloidosis and is the most important determinant of the clinical outcome. The aims of this study were to assess the incidence and prognosis of cardiac amyloidosis and discuss the diagnostic issues related to cardiac amyloidosis. SUBJECTS AND METHODS: We retrospectively studied all patients diagnosed with systemic amyloidosis who presented to our institution from January 1999 to December 2011. RESULTS: Of the 129 patients with systemic amyloidosis, cardiac amyloidosis was diagnosed in 62 patients. At the 3 years' follow-up of the patients with systemic amyloidosis, there was a statistically significant difference in mortality between patients with cardiac amyloidosis and the rest of the patients (58.1% vs. 37.3%, p=0.008). In the Cox proportional hazard model, old age {hazard ratio (HR) 18.336, p=0.006}, elevation of cardiac troponin I (cTNI) (HR 13.246, p=0.020), left ventricular (LV) systolic dysfunction (HR 5.137, p=0.041) and diastolic dysfunction (HR 64.595, p=0.022) were independently associated with survival in cardiac amyloidosis. In the diagnosis of monoclonal gammopathy, serum or urine protein electrophoresis was not sensitive enough to be used clinically compared to serum free light chain assay (35.8% vs. 96.4%). CONCLUSION: In systemic amyloidosis, cardiac involvement was the most important determinant of the prognosis, and old age, elevation of cTNI, LV systolic dysfunction and diastolic dysfunction were independently associated with survival in cardiac amyloidosis.

Impact of Afterload on the Assessment of Severity of Aortic Stenosis

BACKGROUND: Aortic stenosis (AS) is increasingly diagnosed in current aging society. Echocardiography is the most important tool in the assessment of AS and its severity. However, load-dependency of Doppler measurement could affect the accuracy of AS severity assessment. We tried to evaluate the impact of afterload on the assessment of AS severity by modification of afterload using pneumatic compression (Pcom). METHODS: Forty patients diagnosed as moderate or severe AS [effective orifice area of aortic valve (EOAAV) by continuity equation of < 1.5 cm2] were consecutively enrolled. Patients with severely uncontrolled hypertension, severe left ventricular (LV) dysfunction, and other significant valve disease were excluded. Comprehensive echocardiography was performed at baseline to assess AS severity. Then, pneumatic compression of the lower extremities by 100 mmHg was applied to increase LV afterload. After 3 minutes, echocardiography was repeated to assess AS severity. RESULTS: Mean blood pressure was significantly increased under Pcom (p < 0.001), while heart rate remained unchanged. Peak aortic valve velocity (Vmax) was slightly, but significantly decreased under Pcom (p = 0.03). However, Doppler velocity index and EOAAV by continuity equation were not affected by Pcom. CONCLUSION: AS severity assessment by echocardiography was not dependent on the change of LV afterload imposed by Pcom. AV Vmax was slightly decreased with LV afterload increment, but these changes were too small to alter treatment plan of AS patients. EOAAV and Doppler velocity index are more stable parameters for AS severity assessment.