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Continuum of disease versus the fascination with numbers: an ongoing struggle
  1. Sorin V Pislaru,
  2. Patricia A Pellikka
  1. Cardiovascular Diseases, Division of Cardiovascular Ultrasound, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Sorin V Pislaru, Department of Cardiovascular Diseases, Division of Cardiovascular Ultrasound, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA; pislaru.sorin{at}mayo.edu

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Some years ago, a pleasant 76-year-old patient presented to our Valve Clinic for a second opinion on her aortic stenosis (AS). She was reassured by her primary cardiologist that her valve ‘was not quite there yet for surgery’, but continued to be troubled by mild dyspnoea. She just wanted to make sure nothing was missed. Her home echocardiogram showed a valve area of 1.0 cm2, with a peak velocity of 3.8 m/s and a mean gradient of 36 mm Hg; the official interpretation on the home report was that of moderate AS.

Ever since echocardiography was shown to reliably estimate aortic valve gradients and valve area,1 ,2 it has de facto replaced catheterisation for assessment of AS severity. Indeed, both European and American professional societies endorse echocardiography as initial approach, with additional studies (CT, invasive haemodynamic assessment) reserved for those patients in whom disease severity is indeterminate, or when clinical and echocardiographic findings are discordant.3-5 However, the traditional cut-off values used for the definition of severe AS (aortic valve area (AVA) <1.0 cm, mean gradient >40 mm Hg and peak velocity >4 m/s) have been criticised as being …

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