High Gradients & if you think it is severe AS then you can be wrong!

In patients with moderate aortic stenosis (AS), the presence of severe aortic regurgitation (AR) can result in deceptively high transvalvular gradients on echocardiography. This is primarily due to the increased forward stroke volume caused by the regurgitant volume, which augments the flow across the stenotic aortic valve. The elevated flow states exaggerate the pressure gradient, making the AS appear more severe than it truly is. Consequently, relying solely on peak velocities or mean gradients in these mixed lesions can lead to overestimation of AS severity, highlighting the importance of integrating additional parameters such as aortic valve area (AVA), dimensionless index, and careful hemodynamic assessment.

Decision-making in mixed valvular lesions such as concomitant AS and AR is often challenging, as the interplay between the two lesions can obscure the true severity and clinical significance of each. Symptoms may not reliably differentiate the dominant lesion, and conventional severity markers can be misleading. In such cases, adjunctive measures like global longitudinal strain (GLS) can play an important role; a reduced GLS suggests early subclinical left ventricular dysfunction and may support the consideration for surgical intervention even when conventional criteria are inconclusive. This underscores the need for a comprehensive, multimodality evaluation in mixed valvular disease to optimize the timing of intervention and prevent irreversible myocardial dysfunction