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Echocardiographic severity grading in aortic stenosis: no holy grail, only lessons towards patient individualisation
  1. Hector I Michelena1,
  2. Philippe Pibarot2,
  3. Maurice Enriquez-Sarano1
  1. 1Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Department of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec, Canada
  1. Correspondence to Dr Hector I Michelena, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; michelena.hector{at}mayo.edu

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The term ‘severe aortic stenosis (AS)’ carries a hefty prognostic connotation; it should oblige diligent workup, cautious interval follow-up or intervention on the patient.1 Trained as problem solvers, we aspire to develop a ‘theory of everything’ for diagnosis and management of complex illness, and AS has not escaped our efforts. For example, until recently, a patient with normal left ventricular EF unable to generate a mean gradient (MG) >40 mm Hg (or peak velocity >4 m/s) across a calcified and restricted aortic valve was deemed not to harbour severe AS. We now know that this oversimplification may exclude from potentially life-saving intervention a number of ‘paradoxical low-flow’ patients with substantial AS who despite having a normal EF and MG <40 mm Hg, have the same or worse prognosis as patients who generate the time-honoured ‘cut-off’ gradient.2 Thus, flow-dependent echocardiographic parameters (peak velocity and MG), despite having excellent correlation between them1 and proven prognostic value,3 do not always reflect disease severity. Interestingly, the aortic valve area (AVA), a flow-independent parameter, remains abnormally decreased (<1 cm2) in most of these ‘paradoxical low-flow’ patients, serving as a clue for their diagnosis.4

Paradoxical low-flow is partly to blame for the parameter inconsistencies found in echocardiographic severe-AS grading (defined as MG <40 mm Hg and AVA <1 cm2).5 The prevalence of severe-AS grading inconsistencies has now been studied in over 11 000 patients,1 ,5 and one out of three patients exhibits inconsistent severe-AS grading. However, there are also a significant number of patients without paradoxical low-flow (normal flow) and normal EF who also have ‘discordant’ severe AS1 with MG <40 mm Hg and AVA <1 cm2, and the opposite as …

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