The evolving approach to the evaluation of low-gradient aortic stenosis

Severe aortic stenosis (AS) is typically identified by a low valve area (≤1.0 cm²) and high mean gradient (≥40 mm Hg). A subset of patients are found to have a less than severe mean gradient (<40 mm Hg) despite a low valve area. These latter types can present as either low ejection fraction with low-gradient AS (stage D2) or normal ejection fraction with low-gradient AS (stage D3). Determining the true severity of disease within these categories has proved difficult. In this review we illustrate both traditional and novel techniques that can be used for further valvular assessment. We also propose a simple algorithm that can be used to evaluate low-gradient AS.