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Pseudo-severe AS on DSE — EECC MCQ

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HardValvular Heart DiseasePseudo-severe AS on DSEEECC

A 65-year-old man with AS has dobutamine stress echocardiography for low-flow low-gradient AS (LVEF 30%, AVA 0.7 cm², mean gradient 22 mmHg). At peak dobutamine, stroke volume increases by 25% but the AVA increases to 1.2 cm² while the mean gradient only rises to 28 mmHg. What does this indicate?

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Correct answer: E — Pseudo-severe AS — the increase in flow caused the valve to open more, showing AVA >1.0 cm²; the valve is not truly severely stenosed but appeared so due to low flow; AVR is not indicated

Dobutamine stress echo differentiates true vs pseudo-severe AS: True severe AS: flow increases → gradient rises significantly → AVA remains ≤1.0 cm² (the valve is truly stenotic). Pseudo-severe AS: flow increases → AVA opens to >1.0 cm² → gradient rises only modestly (the valve was not fully opening at low flow due to weak LV, but is not intrinsically severely stenosed). This patient's AVA increasing to 1.2 cm² demonstrates that the valve area at rest was limited by low flow, not by true anatomical stenosis. AVR would not benefit this patient (the symptoms are from LV dysfunction, not valve obstruction). Treatment should focus on HF GDMT. CT aortic valve calcium scoring can provide confirmatory data: low calcium (<800 AU in men) supports pseudo-severe AS.

Reference: ESC/EACTS (2025): VHD Guidelines