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Inconsistent grading of aortic valve stenosis by current guidelines: haemodynamic studies in patients with apparently normal left ventricular function
  1. Jan Minners,
  2. Martin Allgeier,
  3. Christa Gohlke-Baerwolf,
  4. Rolf-Peter Kienzle,
  5. Franz-Josef Neumann,
  6. Nikolaus Jander
  1. Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
  1. Correspondence to Dr Jan Minners, Herz-Zentrum Bad Krozingen, Suedring 15, Bad Krozingen 79189, Germany; jan.minners{at}


Background On echocardiography approximately one-third of patients with severe aortic valve stenosis based on aortic valve area (AVA<1.0 cm2) demonstrate a non-severe mean pressure gradient (ΔPm; ≤40 mm Hg) despite apparently normal left ventricular function. It has been suggested that inconsistent echocardiographic grading may be due to ‘paradoxical’ low stroke volume. However, the correct echocardiographic assessment of stroke volume hinges on the often problematic measurement of the left ventricular outflow tract (LVOT) diameter.

Objective To investigate whether inconsistent grading and reduced stroke volume persist when the quantification of aortic valve stenosis is based on cardiac catheterisation which is independent of LVOT measurements.

Methods and results 333 consecutive patients underwent cardiac catheterisation within 30 days after their index echocardiography showing an AVA ≤2 cm2 and shortening fraction ≥30%. On invasive testing 85 patients (26%) demonstrated inconsistent (AVA<1 cm2 and ΔPm≤40 mm Hg) and 153 (46%) consistent grading (AVA<1 cm2 and ΔPm>40 mm Hg) with the remainder (28%) presenting with a calculated AVA≥1 cm2. Inconsistently graded patients were older (71 vs 67 years, p<0.006) with no differences in sex or body surface area between groups. Stroke volume and stroke volume index were significantly lower in inconsistently graded patients (63±14 vs 73±18 ml and 35±7 vs 39±7 ml/m2, respectively, both p<0.001). However, 41/85 (48%) of inconsistently graded patients had a normal stroke volume index >35 ml/m2.

Conclusion In the framework of current guidelines inconsistent grading of aortic valve stenosis is common, extends to cardiac catheterisation and is only partially explained by low stroke volume despite apparently normal left ventricular systolic function.

  • Aortic valve stenosis
  • echocardiography
  • cardiac catheterisation
  • stroke volume
  • guidelines
  • aortic valve disease

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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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