title: Inconsistent grading of aortic valve stenosis by current guidelines: haemodynamic studies in patients with apparently normal left ventricular function.
abstract: BACKGROUND
  On echocardiography approximately one-third of patients with severe aortic valve stenosis based on aortic valve area (AVA<1.0 cm(2)) demonstrate a non-severe mean pressure gradient (DeltaPm; < or =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.
  
  
  RESULTS
  333 consecutive patients underwent cardiac catheterisation within 30 days after their index echocardiography showing an AVA < or =2 cm(2) and shortening fraction > or =30%. On invasive testing 85 patients (26%) demonstrated inconsistent (AVA<1 cm(2) and DeltaPm< or =40 mm Hg) and 153 (46%) consistent grading (AVA<1 cm(2) and DeltaPm>40 mm Hg) with the remainder (28%) presenting with a calculated AVA> or =1 cm(2). 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/m(2), respectively, both p<0.001). However, 41/85 (48%) of inconsistently graded patients had a normal stroke volume index >35 ml/m(2).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany. jan.minners@herzzentrum.de
authors.forename: Jan
authors.initials: J
authors.lastname: Minners
authors.forename: Martin
authors.initials: M
authors.lastname: Allgeier
authors.forename: Christa
authors.initials: C
authors.lastname: Gohlke-Baerwolf
authors.forename: Rolf-Peter
authors.initials: RP
authors.lastname: Kienzle
authors.forename: Franz-Josef
authors.initials: FJ
authors.lastname: Neumann
authors.forename: Nikolaus
authors.initials: N
authors.lastname: Jander
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000473:pathology* / Q000503:physiopathology; D006328:Cardiac Catheterization / Q000379:methods; D005260:Female; D006352:Heart Ventricles / Q000000981:diagnostic imaging / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D013318:Stroke Volume; D014463:Ultrasonography; D016277:Ventricular Function, Left / Q000502:physiology*