Low-Gradient AS: True or Pseudo-Severe Stenosis?

An 82-year-old female patient with a history of calcific aortic stenosis (AS), hypertension treated with angiotensin-converting enzyme inhibitors, and renal failure with creatinine at 2 mg/dl presented with New York Heart Association Class III dyspnea and was recently hospitalized for heart failure. She was treated successfully with diuretics. Her blood pressure at admission was 135/65 mmHg with a body surface area of 1.8 m2, and her heart rate was 90 bpm. The electrocardiogram showed sinus rhythm; there was no evidence of acute ischemic changes. The Doppler-echocardiogram performed during this hospitalization revealed the following:

  • Left ventricular ejection fraction (LVEF) at 75% (Video 1)
  • Left ventricular (LV) end-diastolic diameter = 41 mm
  • Left ventricular outflow tract (LVOT) diameter = 21 mm
  • Left atrial volume index = 35 ml/m2
  • Grade II LV diastolic dysfunction

Parasternal long and short axis views (Videos 2-3) showed thickened and calcified aortic valve (AV) leaflets with reduced opening. There was only mild mitral regurgitation. Stroke volume measured by Doppler method in the LVOT was 59 mL (Figure 1, top). Transvalvular aortic mean gradient was 31 mmHg after multi-window interrogation with continuous wave Doppler, and peak velocity was 3.6 m/s (Figure 1, bottom). Aortic valve area (AVA) by continuity equation was 0.84 cm2, indexed AVA was 0.47 cm2/m2, and Doppler-velocity index was 0.24 (Figure 1). There were no other notable abnormalities.

Figure 1

Figure 1

Video 1

Video 2

Video 3

Which of the following is the best next step in management?

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