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Although data are limited, some studies also reported that AVR and concomitant coronary artery revascularization both had independent beneficial effects on survival (8?and?14). Other factors reported as also having a significant impact on outcome and response to treatment were the degree of myocardial viability and, conversely, the extent of myocardial fibrosis (22, 39?and?40). Reversibility of myocardial fibrosis following AVR likely depends on its type (reactive interstitial vs. replacement) and extent (mild vs. severe) as well as extent of correction of its causal mechanism (i.e., pressure overload and/or myocardial ischemia) (41). A recent study (22) reported more extensive myocardial fibrosis in patients with both types of LF-LG AS compared Selleckchem Q VD Oph with patients with normal flow, high-gradient AS (Fig. 5). Furthermore, longitudinal myocardial shortening was affected to a larger extent in these patients with LF-LG AS due to more advanced fibrosis in the subendocardial layer, where fibers are oriented longitudinally (42). Better standardization and validation are, however, necessary before quantification of myocardial fibrosis by magnetic resonance imaging can be implemented clinically (41). The ACC/AHA guidelines (1) provide no specific recommendation for the treatment of patients with low LVEF, LF-LG AS, whereas the ESC/EACTS guidelines (2) support the utilization of AVR (Class IIa; Level of Evidence: C) in the subset of patients with LV flow reserve. Nonetheless, there presently www.selleckchem.com/products/bay-61-3606.html appears to be a clear consensus that patients with true severe AS and evidence of ��LV flow�� reserve should be considered for AVR and that coronary artery bypass graft surgery should be performed concomitantly whenever necessary. The evidence, albeit limited, is however not as clear in patients with LV flow reserve and pseudosevere AS because prognosis appears to be poor, whatever the treatment (7, 30, 32?and?35). Hence, such patients should probably be treated medically at first, but nonetheless followed up very closely (i.e., every 2 to 3 months), and the therapeutic options reconsidered Thymidine kinase in case of lack of improvement or deterioration (Fig. 2) (35). The outcome of these patients is largely determined by the extent of the imbalance between the degree of myocardial impairment and the degree of AS severity. Hence, although moderate AS may be well tolerated by a normally functioning ventricle, it may have the same impact as a severe stenosis in a failing ventricle. This observation may explain why a substantial proportion of patients with pseudosevere AS have a better prognosis if treated surgically rather than medically (7, 29, 30?and?35). To this effect, the cutoff values of EOA