Dilemma in the therapeutic management of low-gradient aortic stenosis

Grading of aortic stenosis is essential in aortic stenosis management patients. However, despite clear thresholds provided in the guidelines, up to 30% of patients have discordant grading of aortic stenosis. The management of patients with low gradients/velocity despite tight aortic valve area is challenging.

Recent studies demonstrated that patients with or without low flow may have a severe aortic stenosis despite a low gradient. Moreover, aortic valve replacement has been shown to improve outcome in low-gradient aortic stenosis patients with or without low flow. Finally, measurement of aortic valve calcification by multidetector computed tomography is an important tool to assess aortic stenosis severity in these patients.

The presence of a low gradient/velocity despite a tight aortic valve area could be linked to low ejection fraction or low flow with preserved ejection fraction but also with normal flow and normal ejection fraction. In each situation, aortic stenosis could be truly severe or pseudosevere, and the severity of aortic stenosis has to be accurately evaluated for clinical decision-making. Nowadays, two types of interventions are available: surgical and transcatheter aortic valve replacement, whereas conservative management should be considered as a palliative treatment in patients with proven severe aortic stenosis and symptoms or left ventricle dysfunction.