Importance of concomitant functional mitral regurgitation on survival in severe aortic stenosis patients undergoing aortic valve replacement

BACKGROUND Mitral regurgitation(MR)is commonly seen in patients with severe aortic stenosis(AS)undergoing aortic valve replacement(AVR).But the long-term implications of MR in AS are unknown.AIM To investigate MR’s impact on survival of patients undergoing surgical AVR for severe AS.METHODS Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003,287 underwent AVR forming the study cohort.They were followed up to death or till the end of 2019.Chart reviews were performed for clinical,echocardiographic,and therapeutic data.MR was graded on a 1-4 scale.Mortality data was obtained from chart review and the Social Security Death Index.Survival was analyzed as a function of degree of MR.RESULTS The mean age of the severe AS patients who had AVR(n=287)was 72±13 years,46%women.Over up to 26 years of follow up,there were 201(70%)deaths,giving deep insights into the determinants of survival of severe AS who had AVR.The 5,10 and 20 years survival rates were 75%,45%and 25%respectively.Presence of MR was associated with higher mortality in a graded fashion(P=0.0003).MR was significantly associated with lower left ventricular(LV)ejection fraction and larger LV size.Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size.By Cox regression,MR,lower ejection fraction(EF)and larger LV end-systolic dimension were independent predictors of higher mortality(χ^(2)=33.2).CONCLUSION Presence of greater than 2+MR in patients with severe AS is independently associated with reduced survival in surgically managed patients,an effect incremental to reduced EF and larger LV size.We suggest that aortic valve intervention should be considered in severe AS patients when>2+MR occurs irrespective of EF or symptoms.

Evaluation of Patients with Severe Aortic Stenosis after TAVI with Self-Expandable vs. Balloon-Expandable Devices

Background: The introduction of transcatheter aortic valve implantation (TAVI) for the treatment of severe aortic stenosis (SAS) has expanded the therapeutic possibilities for successfully managing SAS in cases with intermediate and high surgical risks. However, the complications and outcomes of new devices have not been studied enough. Hence, the purpose of this study is to evaluate the midterm results of the Core Valve and Evolute R self-expandable (SE) devices versus the Edwards SAPIEN balloon-expandable (BE) devices. Methods and Material: This was a quasi-experimental study conducted in Tehran, Iran, from May 2012 to June 2017. SAS patients who were not ideal candidates for surgery were randomly assigned to either SE or BE groups. For each patient, a questionnaire, including four sections comprised of Basic characteristics, echocardiographic, angiographic, and Computed Tomography (CT) scan data was filled. TAVI was followed by echocardiography a week later and after three months they were reevaluated by another questionnaire. Results: The total number of patients was 60. The mean ages of patients undergoing the procedure with SE or BE devices were 81.2 ± 8 and 79.8 ± 7, respectively. Mortality occurred in 20% of the patients (5 cases in the SE group and 7 cases in the BE);mortality causes were 66.6 % cardiac and 33% non-cardiac. Moderate to severe Paravalvular leakage in both groups did not differ significantly. The mortality rate was 5 (41.6%) in the SE group versus 7 (58.3%) in the BE group (P > 0.05). Conclusion: In conclusion, the BE group did not experience fewer paravalvular leaks in comparison with the SE. Morbidity and mortality between the BE and the SE groups did not differ significantly.

Aortic stenosis： insights on pathogenesis and clinical implications

Aortic stenosis （AS） is a common valvular heart disease in the Western populations, with an estimated overall prevalence of 3% in adults over 75 years. To understand its patho-biological processes represents a priority. In elderly patients, AS usually involves trileaflet valves and is referred to as degenerative calcific processes. Scientific evidence suggests the involvement of an active ＂atherosclerosis-like＂ pathogenesis in the initiation phase of degenerative AS. To the contrary, the progression could be driven by different forces （such as mechanical stress, genetic factors and interaction between inflammation and calcification）. The improved understanding presents potentially new therapeutic targets for preventing and inhibiting the development and progression of the disease. Furthermore, in clinical practice the management of AS patients implies the evaluation of generalized atherosclerotic manifestations （i.e., in the coronary and carotid arteries） even for prognostic reasons. In counselling elderly patients, the risk stratification should address individual frailty beyond the generic risk scores. In these regard, the co-morbidities, and in particular those linked to the global atherosclerotic burden, should be carefully investigated in order to define the risk/benefit ratio for invasive treatment strategies. We present a detailed overview of insights in pathogenesis of AS with possible practical implications.

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis

Aortic stenosis （AS） is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement （SAVR） has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged, Transcatheter aortic valve replacement （TAVR） is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety （e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing）. The impact of comorbidities （pulmonary hypertension, arterial hypertension and obesity paradox）, the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category （extremely high, high, intermediate and low risk） are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.

Effect of transcatheter aortic valve implantation on QT dispersion in patients with aortic stenosis

Background QT dispersion （QTd） is a predictor of ventricular arrhythmia. Ventricular arrhythmia is an important factor influencing morbidity and mortality in patients with aortic stenosis. Surgical aortic valve replacement reduced the QTd in this patients group. However, the effect of transcatheter aortic valve implantation （TAVI） on QTd in patients with aortic stenosis is unknown. The aim of this study was to investigate the effect of TAVI on QTd in patients with aortic stenosis. Methods Patients with severe aortic stenosis, who were not candi-dates for surgical aortic valve replacement due to contraindications or high surgical risk, were included in the study. All patients underwent electrocardiographic and echocardiographic evaluation before, and at the 6th month after TAVI, computed QTd and left ventricular mass index （LVMI）. Results A total 30 patients were admitted to the study （mean age 83.2 ± 1.0 years, female 21 and male 9, mean valve area 0.7 ± 3 mm2）. Edwards SAPIEN heart valves, 23 mm （21 patients） and 26 mm （9 patients）, by the transfemoral approach were used in the TAVI procedures. All TAVI procedures were successful. Both QTd and LVMI at the 6th month after TAVI were significantly reduced com-pared with baseline values of QTd and LVMI before TAVI （73.8 ± 4 ms vs. 68 ± 2 ms, P=0.001 and 198 ± 51 g/m2 vs. 184 ± 40 g/m2, P=0.04, respectively）. There was a significant correlation between QTd and LVMI （r=0.646, P〈0.001）. Conclusions QTd, which malign ventricular arrhythmia marker, and LVMI were significantly reduced after TAVI procedure. TAVI may decrease the possibility of ventricu-lar arrhythmia in patients with aortic stenosis.

Medical management of symptomatic severe aortic stenosis in patients non-eligible for transcatheter aortic valve implantation

1 Transcatheter aortic valve implantation in symptomatic severe aortic stenosis: where do we stand? Aortic stenosis occurs in 2%-9% of patients over the age of 65, the most common cause being degenerative.^([1,2]) The preferred treatment in symptomatic severe aortic stenosis(SAS) is surgical aortic valve replacement(SAVR), but in the elderly, the surgical risk can be greater than the benefit.([3]).

Measuring frailty in patients with severe aortic stenosis:a comparison of the edmonton frail scale with modified fried frailty assessment in patients undergoing transcatheter aortic valve replacement

Frailty is generally defined as a clinical syndrome of decreased physiologic reserve which drives to increased vulnerability and susceptibility to different stressors together with poor recovery to homeostasis.[1]The relevance of frailty status in a wide range of prospective cohorts is mostly related to an increasing burden in both mortality,hospital readmissions,disability,and falls.

A meta-analysis of 1-year outcomes of transcatheter versus surgical aortic valve replacement in low-risk patients with severe aortic stenosis

Background Transcatheter aortic valve replacement(TAVR)for the treatment symptomatic severe aortic stenosis(AS)is indicated in patients with intermediate or higher surgical risk.Latest trials showed TAVR,and surgical aortic valve replacement(SAVR)perform similarly at 1-year for the composite outcomes of mortality,stroke and rehospitalization.We performed a comprehensive meta-analysis to compare individual outcomes at 1-year for TAVR compared to SAVR in low-risk patients.Methods Pub Med,Embase,and Cochrane central were searched for all the randomized controlled trials(RCTs)that reported 1-year comparative outcomes of TAVR and surgical aortic valve replacement(SAVR).Our conclusions are based upon the random-effects model using Der Simonian-Laird estimator.Results Data from 4 trials and 2887 randomized patients showed that TAVR had lower rates of all-cause mortality,cardiovascular mortality,and atrial fibrillation compared to SAVR at 1-year follow-up(P<0.05 for all).Also,TAVR was also associated with a significantly higher risk of permanent pacemaker implantation and moderate-severe paravalvular leak(P<0.05).Conclusions The latest randomised trial data demonstrates that in short-term,TAVR is safe and effective in reducing all-cause mortality or stroke.Longer follow-up of RCTs is needed to determine the durability of clinical benefits in TAVR over SAVR in low-risk patients.

New Insight in the Assessment of Left Ventricular Function in Paradoxical Low Flow Aortic Stenosis Patients with Normal Left Ventricular Ejection Fraction: A Mini-Review

Paradoxical valvular aortic stenosis (VAS) is a challenging area of clinical cardiology for the practitioners. It involves a small aortic valve area, low flow rate and mean pressure gradient although there is normal left ventricular ejection fraction. The aim of this study was to assess left ventricular (LV) dysfunction in a symptomatic severe aortic valve stenosis which is of crucial importance in identifying patients at risk of heart failure, postoperative complications and increased mortality. There are new insights which are involved in assessment of LV myocardial function including global longitudinal strain (GLS) by two-dimensional speckle tracking echocardiography (2D STE), myocardial performance index (MPI) and maximum rate of LV pressure rise (+dP/dt) during isovolumetric contraction time of the LV. This information can provide both diagnostic and prognostic information in addition to standard echocardiographic and clinical parameters. However, a profound understanding of the complex interaction between loading conditions, chamber geometry and contractility is necessary for the correct interpretation of myocardial deformation in order to draw appropriate conclusions in patients with aortic valve disease. This mini review is related to new and novel insights into the assessment of left ventricular function (LVF) in paradoxical low flow aortic stenosis patients with normal left ventricular ejection fraction (LVEF).

Balloon valvuloplasty as destination therapy in elderly with severe aortic stenosis： a cardiac catheterization study

Background In the current era of transcatheter aortic valve replacement, there is renewed interest in balloon aortic valvuloplasty （BAV） and invasive hemodynarnic evaluation of aortic stenosis （AS）. The current report aimed to study the invasive hemodynamics of se- vere AS patients treated with BAV as destination therapy and to identify factors associated with better hemodynamic outcome and prognosis. Methods From 2009 to 2012, 63 high risk elderly patients were treated with BAV as destination therapy for symptomatic severe AS and were all prospectively included in the study. Their hemodynamies were invasively evaluated during catheterization, pre- and post-BAV at the same session. All Post-BAV patients were regularly followed-up. Results The patients （82 ~ 6 years, 52% male） had post-BAV aortic valve area index （AVAi） significantly increased and mean pressure gradient （MPG） significantly reduced. During the follow-up of 0.9 （maximum 3.3） years, those with post-BAV AVAi 〈 0.6 cm2/m2 compared with the AVAi _〉 0.6 cm2/m2 group had significantly higher mortality （60% vs. 28%, log-rank P = 0.02）, even after adjusting for age, gender, atrial fibrillation, chronic kidney disease, diabetes mellitus, coronary artery disease and EuroSCORE [HR： 5.58, 95% confidence interval （CI）： 1.62-19.20, P = 0.006]. The only independent predictor of moderate AS post-BAV was the pre-BAV AVAi increase by 0.1cm^2/m^2 （OR： 3.81, 95% CI： 1.33-10.89, P = 0.01）. Pre-BAV AVAi 〉 0.39 cm^2/m^2 could predict with sensitivity 84% and specificity 70% the post-BAV hemodynamic outcome. Conclusions BAV as destination therapy for severe AS offered immediate and significant hemodynamic improvement. The survival was significantly better when a moderate degree of AS was present.

The Prognostic Value of Myocardial Deformation in Patients with Congenital Aortic Stenosis

Aims:To assess the prognostic value of left ventricular(LV)global longitudinal strain(GLS)and global longitudinal early diastolic strain rate(GLSre)with regard to cardiovascular events,as congenital aortic stenosis(AoS)is associated with significant mortality and morbidity but predictors for clinical outcome are scarce.Strain analysis provides a robust and reproducible method for early detection of LV dysfunction,which might be of prognostic value.Methods:This prospective study,included clinically stable patients with congenital AoS between 2011–2013.LV GLS and GLSre was performed in the apical 4,3 and 2-chamber views using Tomtec software.The endpoint was a composite of death,heart failure,hospitalization,arrhythmia,thrombo-embolic events and re-intervention.Results:In total 138 patients were included(33[26–43]years,86(62%)male),NYHA class I:134(97%).Mean LV GLS was–15.3±3.2%,GLSre 0.66±0.18 s–1.Both correlated with NT-proBNP,LV volumes and ejection fraction(strongest LV GLS with LV EF:r–0.539,p<0.001,strongest LV GLSre with age:r–0.376,p<0.001).During median follow-up of 5.9[5.5–6.2]years,the endpoint occurred in 53(38%)patients:4 patients died,9 developed heart failure,22 arrhythmias,8 thrombo-embolic events and 35 re-interventions.Both LV GLS(standardized HR(sHR 0.62(95%CI 0.47–0.81)and GLSre(sHR 0.62(95%CI 0.47–0.83)were associated with the endpoint.Additional multivariable analysis showed that both GLS and GLSre were associated independent of left atrial volume,NT-proBNP and prior re-interventions.Conclusion:Left ventricular GLS and GLSre are reduced in adult patients with congenital AoS.Both markers are associated with adverse cardiac events and have clear clinical relevance.

Circulating CD14＋ monocytes in patients with aortic stenosis

BackgroundCalcific aortic stenosis （AS） is an active process sharing similarities with atherosclerosis and chronic inflammation. The pathophysiology of AS is notable for three cardinal components： inflammation, fibrosis and calcification. Monocytes play a role in each of these processes. The role of circulating monocytes in AS is not clear. The aim of the present study was to study an association between cir-culating apoptotic and non apoptotic CD14＋ monocytes and AS features.MethodsWe assessed the number of CD14＋ monocytes and apoptotic monocytes in 54 patients with significant AS （aortic valve area 0.74 ± 0.27 cm2） and compared them to 33 patients with similar risk factors and no valvular disease. The level of CD14＋ monocytes and apoptotic monocytes was assessed by flow cytometry.ResultsThere was no difference in the risk factor profile and known coronary or peripheral vascular diseases between patients with AS and controls.Pa-tients with AS exhibited increased numbers of CD14＋ monocytes as compared to controls （9.9% ± 4.9%vs. 7.7% ± 3.9%,P= 0.03）. CD14＋ monocyte number was related to age and the presence and severity of AS. In patients with AS, both CD14＋ monocytes and apoptotic mono-cytes were inversely related to aortic valve area.ConclusionsPatients with significant AS have increased number of circulating CD14＋ monocytes and there is an inverse correlation between monocyte count and aortic valve area. These findings may suggest that inflammation is operative not only in early valve injury phase, but also at later developed stages such as calcification when AS is severe.

Aortic stenosis and Heyde’s syndrome:A comprehensive review

Heyde’s syndrome is an under reported systemic disease of gastrointestinal and cardiac manifestation in older adults.It is characterized by a triad of aortic stenosis,angiodysplasia with bleeding and acquired von Willebrand syndrome.It is characterized by proteolysis of high molecular weight multimers of von Willebrand Factor and loss of platelet mediated homeostasis.Heyde’s syndrome is a treatable condition in most cases,especially in the current era of evolution in interventional cardiology and gastroenterology.There are currently no established guidelines in the management of this condition due to paucity of high quality studies,which warrant future trials.High index of suspicion and increasing the awareness of the syndrome among the general practitioners and sub-specialists will improve the diagnostic potential of Heyde’s syndrome.Future studies may change the management aspect of Heyde's syndrome and pave a path for drawing specific guidelines and algorithms.The aim of our review article is to summarize the basic pathophysiology,diagnostics and management of Heyde’s syndrome with a special attention to Transcatheter aortic valve replacement.

Rapid right ventricular pacing for balloon valvuloplasty in congenital aortic stenosis:A systematic review

BACKGROUND Balloon aortic valvuloplasty(BAV)is a well-established treatment modality for congenital aortic valve stenosis.AIM To evaluate the role of rapid right ventricular pacing(RRVP)in balloon stabilization during BAV on aortic regurgitation(AR)in pediatric patients.METHODS A systematic review of the MEDLINE,Cochrane Library,and Scopus databases was conducted according to the PRISMA guidelines(end-of-search date:July 8,2020).The National Heart,Lung,and Blood Institute and Newcastle-Ottawa scales was utilized for quality assessment.RESULTS Five studies reporting on 72 patients were included.The studies investigated the use of RRVP-assisted BAV in infants(>1 mo)and older children,but not in neonates.Ten(13.9%)patients had a history of some type of aortic valve surgical or catheterization procedure.Before BAV,58(84.0%),7(10.1%),4(5.9%)patients had AR grade 0(none),1(trivial),2(mild),respectively.After BAV,34(49.3%),6(8.7%),26(37.7%),3(4.3%),patients had AR grade 0,1,2,and 3(moderate),respectively.No patient developed severe AR after RRVP.One(1.4%)developed ventricular fibrillation and was defibrillated successfully.No additional arrhythmias or complications occurred during RRVP.CONCLUSION RRVP can be safely used to achieve balloon stability during pediatric BAV,which could potentially decrease AR rates.

Importance of frailty and comorbidity in elderly patients with severe aortic stenosis

The progressive aging of the population has risen awareness and concern about the impact of geriatric syndromes on both clinical outcomes and health-related quality of life in elderly patients, as well as issues regarding the rising economic burden associated with healthcare. Recent studies have demonstrated frailty and other geriatric syndromes such as functionality, dependency and comorbidity can identify the most vulnerable patients, thus allowing to better estimate the individual prognosis in terms of disability, readmission and mortality. Such information should also be considered in the decision making process, ensuring the benefit derived from each treatment in each patient, optimizing the resources and avoiding futility.

Single-Stage Repair of a Critical Aortic Coarctation, a Bicuspid Aortic Stenosis and an Ascending Aortic Aneurysm

We report a 26-year-old man with critical aortic coarctation, severe bicuspid aortic valve stenosis, infective endocarditis and ascending aortic aneurysm. He underwent simultaneously in singlestage a Bentall’s procedure and an extra-anatomic ascending-descending aortic bypass grafting by 14-mm Dacron tube, through median sternotomy. The immediate postoperative outcome was favourable. The CT scan control for 7 years after surgery showed a good patency of the extra-anatomic bypass.

Aortic Stenosis and Stressed Heart Morphology

Myocardial geometric remodeling is a response to increased stress which includes increased afterload situations during clinical conditions. In this review, we have focused on early and late geometric features in aortic stenosis, importance of recognition of these findings and consequences due to progression of valve disease. We have also pointed out the similarities in early focal and global myocardial geometric remodeling in acute and chronic conditions as hypertension and acute stress cardiomypathy which are associated with myocardial functional and geometric response to acute or chronic stress exposure and relevant increased afterload. In aortic stenosis, target organ involvement in disease progression has been evaluated and discussed in the report. In addition to quantitative evaluation of valve disease, importance of myocardial involvement and global assessment of patients with aortic stenosis also have been mentioned in the report. Finally, we have discussed the importance of global myocardial geometric changes and timing for surgery before development of heart failure in this specific group of patients.

Balloon aortic valvuloplasty as a bridge-to-decision in high risk patients with aortic stenosis： a new paradigm for the heart team decision making

Background Whilst the majority of the patients with severe aortic stenosis can be directly addressed to surgical aortic valve replace- ment （AVR） or transcatheter aortic valve implantation （TAVI）, in some instances additional information may be needed to complete the diagnostic workout. We evaluated the role of balloon aortic valvuloplasty （BAV） as a bridge-to-decision （BTD） in selected high-risk patients. Methods Between 2007 and 2012, the heart team in our Institution required BTD BAV in 202 patients. Very low left ventricular ejection fraction, mitral regurgitation grade 〉 3, frailty, hemodynamic instability, serious comorbidity, or a combination of these factors were the main drivers for this strategy. We evaluated how BAV influenced the final treatment strategy in the whole patient group and in each specific subgroup. Results Mean logistic European System for Cardiac Operative Risk Evaluation （EuroSCORE） was 23.5%±15.3%, age 81 ± 7 years. In-hospital mortality was 4.5%, cerebrovascular accident 1% and overall vascular complications 4% （0.5% major; 3.5% minor）. Of the 193 patients with BTD BAV who survived and received a second heart team evaluation, 72.6% were finally deemed eligible for definitive treatment （25.4% for AVR; 47.2% for TAVI）： 96.7% of patients with left ventricular ejection fraction recovery; 70.5% of patients with mitral regurgitation reduction; 75.7% of patients who underwent BAV in clinical hemodynamic instability; 69.2% of frail patients and 68% of patients who presented serious comorbidities. Conclusions Balloon aortic valvuloplasty can be considered as bridge-to- decision in high-risk patients with severe aortic stenosis who cannot be immediate candidates for definitive transcatheter or surgical treatment.

The effects of severe aortic stenosis and high pulmonary artery pressure on aortic valve replacement

Background: Pulmonary hypertension development in pure severe aortic stenosis is a situation that affects mortality and morbidity. Material and Methods: Data from files of 31 patients with systolic pulmonary artery pressure over 50 mm Hg and with pure severe aortic stenosis, and underwent aortic valve replacement in our clinic were examined retrospectively. Results: Preoperative effort capacities of the patients were evaluated as follows according to NYHA;4 patients class 1-2, 16 patients class 3, and 11 patients class 4. Twenty-five metal, and 6 biologic aortic valves were used. Postoperative hospital mortality was recorded as 12% with 4 patients. Patients were reevaluated on the postoperative 2nd and 12th months. Pulmonary arterial pressure of the patients was measured using echocardiography. Preoperative average pulmonary artery systolic pressure was measured as 55 ± 3 mmHg. The average pressure was measured as 41 ± 3 mmHg on the 2nd, and as 37.8 ± 4 mmHg on the 12th month. The effort capacity evaluation in the postoperative 2nd month was as follows: 11 patients class 1-2, 12 patients class 3, and 4 patients class 4. The effort capacity evaluation conducted in the 12th month was: 14 patients were class 1-2, 10 patients were class 3, and 2 patients were class 4. During the follow-up 1 year, survival rate of the patients was determined as 83.8% average, 5 year survival rate was determined as 61.5%. Conclusion: We believe that AVR may be performed in severe aortic stenosis cases with high pulmonary pressure with acceptable ortality, leading to a better quality and longer life.

Paradoxical Low Flow Low Gradient Severe Aortic Stenosis—An Under-Recognized Entity

Some patients with severe aortic stenosis (AS), due to restrictive cardiac physiology, paradoxically have relatively low flow and low gradients across stenotic aortic valves despite preserved left ventricular (LV) systolic function. It results in symptoms and reduced quality of life and carries a high mortality. Whilst this form of severe AS, termed paradoxical low flow low gradient (pLFLG), is well reported, patients with this diagnosis experience inappropriate barriers to aortic valve replacement (AVR), the only efficacious treatment. We present the case of an 88-year-old female with 12 months of exertional dyspnoea on a background of hypothyroidism and hypercholesterolemia. Transthoracic echocardiogram (TTE) revealed LV hypertrophy, with a small LV cavity size and reduced stroke volume, yet normal systolic function. A heavily calcified aortic valve was identified with severe aortic stenosis, based on valve area, yet with incongruous mean transvalvular gradient of 25 mmHg (severe ≥ 50 mmHg). Following exclusion of other differential diagnoses, her symptoms were attributed to paradoxical LFLG severe AS. She was however declined definitive transcatheter aortic valve implantation (TAVI) due to her paradoxically low mean aortic gradient. Following further deterioration in her symptoms and supportive quantification of poor exercise performance, she was ultimately re-referred, accepted, and underwent TAVI. Following her AVR, the patient experiences significant improvement in both symptoms and quality of life after only one month. Paradoxical LFLG severe AS remains a well-documented yet under recognized disease. It carries high morbidity and mortality if untreated, yet is significantly less likely to be referred and accepted for intervention. With its prevalence expected to rise with an ageing population, this case serves as a timely reminder for clinicians to address the under recognition of important pathology.