Eighty-four patients with aortic valve stenosis (AS) and without other valvular or coronary artery disease were studied to investigate the pathophysiologic importance of hemodynamic and functional factors in the development of congestive heart failure (CHF). Thirty had clinical and radiographic signs of CHF. There was no significant difference between patients with and those without CHF in aortic valve index (0.26 +/- 0.09 vs 0.34 +/- 0.16 cm2/m2), mean aortic valve gradient (64 +/- 19 vs 59 +/- 25 mm Hg), left ventricular (LV) systolic pressure (201 +/- 31 vs 201 +/- 35 mm Hg), LV end-diastolic diameter (4.8 +/- 1.0 vs 4.4 +/- 0.7 cm) or posterior LV wall thickness (14.0 +/- 4.7 vs 15.0 +/- 30.0 mm). Patients with CHF had higher LV end-diastolic pressure (22 +/- 10 vs 16 +/- 7 mm Hg, p less than 0.005) and LV wall stress (370 +/- 138 vs 300 +/- 69 g/cm2, p less than 0.005) and lower cardiac index (2.0 +/- 0.5 vs 2.4 +/- 0.6 liters/min/m2, p less than 0.005) and LV ejection fraction (55 +/- 18 vs 68 +/- 13%, p less than 0.0005). An inverse linear relation (r = -0.59, p less than 0.01) was present between LV wall stress and LV ejection fraction such that as stress increased, LV ejection fraction fell. Values for both LV wall stress and LV ejection fraction overlapped considerably between the groups and, more important, only 40% of patients with CHF had a depressed LV ejection fraction.(ABSTRACT TRUNCATED AT 250 WORDS)