Pitfalls and Challenges in the Echocardiographic Diagnosis of Aortic Stenosis

Abstract

Aortic stenosis is the most prevalent valvulopathy in the developed world, and increasing numbers of elderly patients are considered for aortic valve replacement. Echocardiography displaced catheterisation from its long-standing use in the diagnosis of aortic stenosis and offers a simple, reliable, non-invasive method that is suitable for follow-up for the assessment of aortic stenosis patients. The truly complex nature of the haemodynamic patterns in these patients is responsible for possible inconsistencies and apparently unclear echocardiographic results. Patients with only mild aortic stenosis as supported by valve appearance and calculated area may nevertheless exhibit surprisingly high gradients. On the other hand, patients with truly severe aortic stenosis may have only modestly elevated gradients, whether due to decreased left ventricular function or to other mechanisms still under investigation. This article reviews the frequently encountered ‘puzzling’ echocardiographic scenarios together with their most likely haemodynamic background and significance in terms of final diagnosis and clinical management.