Valvular aortic stenosis (AS) is a progressive disorder that results in impairment of blood flow to the systemic circulation. Once it has become severe and associated with symptoms, death is imminent if the obstruction is not relieved. However, several recent studies have sparked new controversies regarding the optimal management of symptomatic patients with AS.

Determining whether a patient with AS is symptomatic and if symptomatic, whether the symptoms are attributable to AS is not always straightforward. Many patients with degenerative calcific AS have comorbidities that may account for symptoms of chest pain, dyspnoea and pre-syncope. Additionally, comorbidities may make the elderly patient so limited that no exertion and therefore, no exertional symptoms occur. In a recent community-based study of patients with AS, most of whom were elderly, cardiac symptoms were unrelated to AS severity.1

Additionally, the echocardiographic criteria for definition of AS as severe2 have been called into question. Whereas peak aortic valve (AV) velocities and gradients are inversely related to Doppler-derived AV areas, it is recognised that a mismatch is present in a substantial percentage of patients with AS, even in those patients with normal LVEF.3 In some patients, this discrepancy is accounted for by the presence of reduced stroke volume; ventricular remodelling with increasing relative wall thickness and reductions in LV end-diastolic diameter and mitral inflow deceleration time is associated with stroke volume index <35 mL/m², which contributes to a lower AV gradient even when the AS is severe.4 In other patients with extremes of body habitus, the haemodynamic consequences of AV area may be better reflected by indexing the value to body surface area; whereas an AV area of 1.0 cm² may not be associated with symptoms or LV hypertrophy in a petite patient, a similar valve area may severely compromise a …