the aortic stenosis can differentiate in 3 parts:
1. high grade aortic stenosis with impaired LV-EF (EF < 50%, SVI < 35 ml/m^2 surface area); the transaortic PGmean in cw will underestimate the grade of aortic stenosis; the continuity-formula can help, but the problem is the right measurement of LVOT-diameter (frquently we measure the LVOT-diameter too small; beside the “real” LVOT-area is not round but rather oval). In my opinion the planimetria with TEE is one of the optimal procedure to graduate the aortic stenosis. Stress-echocardiography can show us the contractile reserve of LV (“will there be an increase of LV-myocardial function after aortic-surgery.”) and we can see, whether there is a “pseudostenosis” (“no full aperture of aortic stenosis because of low LV-contractility.”) or a real “fixed” stenosis.
What do you think: will the dimensionless index (LVOT-VTO/ Aortic-VTI < 0,25) show us the real graduation of aortic stenosis?
2. aortic stenosis with preserved LV-EF (EF > 50%, SVI > 35 ml/ m^2 surface area); the transaortic PGmean in cw often shows us the “real” graduation aof aortic stenosis, but body size/ body surface area and the measurement of LVOT-area will be a problem to graduate the aortic stenosis in the right way. But what is with “inconsistent gradient”?
What is your way to solve that problem with “inconsistent gradient”: Aortic-area < 1 cm^2 as a sign for high grade aortic stenosis and a PGmean < 40 mmHg as a sign for middle grade aortic stenosis. I Think that in that case the clinical affictions will show us, whether the patient can treat conventional or surgical.
3. high grade aortic stenosis with preserved LV-EF but low stroke volume (LV-EF > 50%, SVI < 35 ml/m^2 surface area); the reason is a distinct mitral valve insufficiency/ tricuspid valve insufficiency, LV-hypertrophy (small LV-cavum, that means a small stroke volume) or atrial fibrillation with impaired LV-filling or distinct diastolic impairment. Is the planimetria by TEE enough for that patients? Do you have any idea ofr right measurement?
At the end: do you think, that invasive measurement (using Golrin-formula) can show us the right way??? I think, that Gorlin-formula shows us the “anatomical” aortic area but not the “effective”/ clinically relevant aortic area of aortic stenosis.
Overall in my opinion the graduation of aortic stenosis is a real challenge for all of us and I have to confess, that it is sometimes very difficult.
I look foward to any comment and hope that you have some hints, tipps and tricks.
Best wishes and regards to you,