True-Severe or Pseudo-Severe AS?
A 75-year-old male patient with a history of systolic heart failure presented with worsening dyspnea (New York Heart Association Class 3 versus 2 at previous visit). On physical examination, his blood pressure was 125/79 mmHg, and he had a rough systolic murmur with blunted S2 in the aortic area. His pulmonary auscultation was normal, and there were no signs of congestion. On echocardiography, the left ventricle showed global hypokinesia, and the left ventricular ejection fraction (LVEF) was 40%. The aortic valve appeared thickened with reduced opening (Video 1).
The transvalvular mean gradient (MG) and peak aortic jet velocity were 19 mmHg and 2.93 m/s, respectively, and the aortic valve area (AVA) was calculated at 0.86 cm2 with a stroke volume of 59 ml/beat (i.e. 28 ml/m2 when indexed to body surface area) (Figure 1A); the mean flow rate was 197 ml/s. The patient underwent low-dose (i.e., 20 mcg/kg/min) dobutamine stress echocardiography (DSE) (Figure 1B) to confirm severity of aortic stenosis (AS). At peak dobutamine stress, the MG, peak aortic velocity, and AVA were 31 mmHg, 3.73 m/s, and 0.86 cm2, respectively, with a stroke volume of 64 ml (30 ml/m2) and a mean flow rate of 221 ml/s.
What is the severity of the AS, and what are the next steps in the management of this patient?