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Assessment of aortic stenosis severity: when the gradient does not fit with the valve area
  1. Philippe Pibarot,
  2. Jean G Dumesnil
  1. Québec Heart and Lung Institute, Department of Medicine, Laval University, Québec, Canada
  1. Correspondence to Dr Philippe Pibarot, Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec, Quebec, Canada; philippe.pibarot{at}med.ulaval.ca

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In this issue of Heart, Minners et al1 (see page 1463) provide an extension of their previous work2 where they retrospectively analysed the data of their Doppler-echocardiography laboratory and reported that there is a discrepancy in the criteria of aortic valve area (AVA; <1.0 cm2) and mean gradient (>40 mm Hg) proposed in the guidelines to define severe aortic stenosis (AS).2 In the present study1 they present data obtained by cardiac catheterisation in a subset of the previous series.2 The main findings of this study are: (1) when using the framework of the current guidelines, inconsistent grading of AS (ie, AVA <1.0 cm2 but gradient ≤40 mm Hg) occurred in 36% of patients with preserved left ventricular (LV) systolic function (LV ejection fraction (LVEF) ≥50%), and this proportion was similar irrespective of the method used to assess stenosis severity (ie, Doppler-echocardiography vs cardiac catheterisation); and (2) the proportion of patients with reduced stroke volume (stroke volume index ≤35 ml/m2) despite apparently normal LV systolic function was substantially higher in the subset of patients with inconsistent grading (52%) than in those with consistent grading (29%).

This latter finding lends further support to the concept that discordance between AVA and gradient is often due to paradoxical low-flow AS, a disease pattern recently described by our group.3 We indeed reported that an important proportion of patients with severe AS may paradoxically have a low flow and thus often a low gradient, despite the presence of normal LVEF.3 When compared with patients with normal LV outflow, patients with paradoxical low flow are characterised by a higher prevalence of women and concomitant hypertension, older age, a higher degree of LV concentric remodelling, impaired LV filling, smaller end-diastolic volume and reduced mid-wall and longitudinal shortening. These patients also have markedly increased global …

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