Marie-Annick Clavel et al. JIMG 2017;10:

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Marie-Annick Clavel et al. JIMG 2017;10:185-202 Case of Paradoxical Low-Flow, Low-Gradient AS An 82-year-old woman with New York Heart Association functional class III dyspnea and recent hospitalization for heart failure. This patient has a small LV cavity with pronounced concentric remodeling, severe diastolic dysfunction, impaired global longitudinal strain (−13%), and dilated left atrium (A) (Online Video 3). The valve appears to be severely thickened and calcified with restricted opening (Online Video 4). The stroke volume measured in the LV outflow tract is 53 ml (B and C), and this patient has a low-flow state (stroke volume index <35 ml/m2). The LV end-diastolic diameter measured apical to the septal bulge (where the diameter is the largest) was 42 mm. The total LV stroke volume estimated with modified Teichholz formula is 51 ml (LV end-diastolic volume by Teichholz: 79 ml × LVEF by Simpson: 65%), which is consistent with the LVOT stroke volume. The total stroke volume measured by 3D echocardiography was 56 ml (not shown), also consistent with the LVOT stroke volume. It is also important to perform multiwindow interrogation with continuous-wave Doppler (D and E). In this patient, a slightly higher velocity was obtained at the right parasternal border window (E). In this patient, the AVA, AVAi, and DVI are in the severe range, but the mean gradient is low (26 mm Hg). The presence of severe stenosis was corroborated by the presence of very high aortic valve calcium score at MDCT (see Figure 7, right panel). The patient underwent transcatheter AVR. AVAi = indexed aortic valve area; diam. = diameter; DVI = Doppler velocity index; LVEDV = left ventricular end-diastolic volume; LVOT = left ventricular outflow tract; other abbreviations as in Figure 2. Marie-Annick Clavel et al. JIMG 2017;10:185-202 American College of Cardiology Foundation