Severe or Faking It? Discordant Aortic Stenosis, Every Scenario

Valve area says severe. The gradient says moderate. The valve says nothing. This deep-dive gives you a complete approach to discordant aortic stenosis: why the cut-offs disagree, how 3 mm can change a grade, when to use dobutamine and CT calcium, how to catch a pseudo-severe valve, and how to decide. Six illustrative cases, each with a "pause and decide" moment. Chapters 0:00 Severe or faking it? 0:47 Why area, gradient and velocity disagree 2:18 Measure twice: outflow tract and Doppler checks 4:16 Low gradient, reduced EF: dobutamine and flow reserve 7:27 Paradoxical low flow with preserved EF 9:13 CT calcium thresholds, traps and amyloid 11:05 High gradient with a larger valve area 12:39 Deciding: TAVI, surgery, asymptomatic and moderate AS 15:17 Evidence corner 16:20 Top 5 pitfalls and the one-page algorithm What you'll learn • Why a valve area of 1.0 cm² does not match a mean gradient of 40 mmHg, and why discordance is built into the cut-offs • How a 3 mm outflow tract error changes the grade, and how the velocity ratio catches it • How to read low-dose dobutamine: flow reserve, true severe vs pseudo-severe, and projected valve area • Sex-specific CT calcium thresholds and their traps in bicuspid valves and advanced kidney disease • When a high gradient with a larger valve area is severe, and when flow, regurgitation or pressure recovery explain it • Who gets a valve under the 2025 ESC/EACTS guideline, and what early-intervention and moderate AS trials do and do not show References 1. Praz F et al. 2025 ESC/EACTS valvular heart disease guidelines. Eur Heart J 2025;46:4635. https://doi.org/10.1093/eurheartj/eha... 2. Otto CM et al. 2020 ACC/AHA valvular heart disease guideline. Circulation 2021;143:e72. https://pubmed.ncbi.nlm.nih.gov/33332... 3. Baumgartner H et al. EACVI/ASE aortic stenosis update. Eur Heart J Cardiovasc Imaging 2017;18:254. https://doi.org/10.1093/ehjci/jew335 4. Minners J et al. Eur Heart J 2008;29:1043. https://www.pubmed.gov/18156619/ 5. Hakki AH et al. Circulation 1981;63:1050. 6. Hachicha Z et al. Circulation 2007;115:2856. https://doi.org/10.1161/CIRCULATIONAH... 7. Jander N et al. (SEAS). Circulation 2011;123:887. https://doi.org/10.1161/CIRCULATIONAH... 8. Eleid MF et al. Circulation 2013;128:1781. https://pubmed.ncbi.nlm.nih.gov/24048... 9. Orwat S et al. EuroIntervention 2013;9:S38. 10. Annabi MS et al. J Am Coll Cardiol 2018;71:475. 11. Ribeiro HB et al. (TOPAS-TAVI). J Am Coll Cardiol 2018;71:1297. 12. Clavel MA et al. J Am Coll Cardiol 2013;62:2329. 13. Pawade T et al. Circ Cardiovasc Imaging 2018;11:e007146. 14. Ye Z et al. Heart 2023. Sheashaa H et al. Int J Cardiol 2026. Dong T et al. Circ Cardiovasc Imaging 2025. 15. Stehli J et al. Front Cardiovasc Med 2023;10:1256970. https://doi.org/10.3389/fcvm.2023.125... 16. Nitsche C et al. J Am Coll Cardiol 2021;77:128. https://doi.org/10.1016/j.jacc.2020.1... 17. Généreux P et al. (EARLY TAVR). N Engl J Med 2025;392:217. 18. Loganath K et al. (EVOLVED). JAMA 2025;333:213. 19. Généreux P et al. (PROGRESS). N Engl J Med 2026. https://doi.org/10.1056/NEJMoa2607326 20. Van Mieghem NM et al. (TAVR UNLOAD). J Am Coll Cardiol 2024. https://doi.org/10.1016/j.jacc.2024.1... Real echo: AMC Echolab / CardioNetworks ECHOpedia, Wikimedia Commons, CC BY-SA. Rheumatic aortic stenosis gross pathology image: Wikimedia Commons. Other visuals are original animation. Educational content for doctors and trainees. Not medical advice; apply to individual patients using your own clinical judgement and local guidance. All cases are illustrative. Reviewed by a practising cardiologist before publishing. #Cardiology #AorticStenosis #Echocardiography