Prophylactic Valve Replacement for Mild Aortic Valve Disease at Time of Surgery for Other Cardiovascular Disease?...No*

Journal of the American College of Cardiology Vol. 33, No. 7, 1999 1999 by the American College of Cardiology ISSN 0735-1097/99/$20.00 Published by Elsevier Science Inc. PII S0735-1097(99)00093-5 EDITORIAL COMMENT Prophylactic Valve Replacement for Mild Aortic Valve Disease at Time of Surgery for Other Cardiovascular Disease?...No* Shahbudin H. Rahimtoola, MB, FRCP, MACP, MACC Los Angeles, California The issue of prophylactic aortic valve replacement (AVR) or repair at time of open-heart surgery for other cardiovascular surgery arises in several clinical situations. For example, at the time of surgery for 1) rheumatic mitral valve disease, 2) coronary artery disease (CAD) and 3) ascending aortic disease. Severe aortic valve disease. Aortic valve replacement is recommended in selected asymptomatic patients with isolated severe aortic stenosis (AS), aortic regurgitation (AR), AS/AR (1 3). Thus, there is probably no controversy that if AS or AR is severe, prophylactic AVR should be performed at time of other valvular, cardiac, coronary and ascending aortic surgery. See page 2003 Mild aortic valve disease. RHEUMATIC MITRAL VALVE DIS- EASE. Sir William Broadbent (4) stated 100 years ago that The age of the patient at the time when the lesion is acquired is the most important consideration in prognosis... This was confirmed in the study of Goldschlager et al. (5) and also in the current era by the seminal study of Bonow et al. (6). More recently, Spagnuolo et al. (7) reported on 174 young patients with rheumatic heart disease from Irvington House and Bellevue Hospitals, New York, who were entered into the registry from 1952 through 1966. Patients in the low-risk group (probably those with less than severe AR) (Table 1) had an outcome that was better than that of a patient with a prosthetic heart valve (please see following section). In this issue of the Journal, Vaturi et al. (8) report on the natural history of mild AVD in 131 patients aged 61 12 years, and followed from 1975 to 1992 for 13 7 years *Editorials published in Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the LACT USC Medical Center, Division of Cardiology, Department of Medicine, Los Angeles County and University of Southern California, Los Angeles, California. (range 1 to 33 years, median 13 years) after surgery for rheumatic mitral valve disease. Of 131 patients, 59 (42%) had AVD (mild in all); 52 of the 59 (88%) had AR, 1 had AS and 6 (10%) had mixed AS/AR. At the end of follow up, 96 (73%) of the patients had AVD; 63 of the 96 (66%) had AR, 6 (6%) had AS and 27 (28%) had AS/AR. Severe AS or AR was present in only 2 and 1 patients, respectively; all 3 initially were in the AS/AR group. It is of interest that of the 6 patients who required surgery on follow up, 4 were primarily for re-operation of the mitral valve and only 2 for severe AS. There are limitations to the study of Vaturi et al. (8). Of 424 patients with rheumatic mitral valve disease, 83 patients died during the first year (64 in-hospital deaths and 19 died during one year follow-up) and 200 patients had inadequate follow-up, leaving 131 patients in the study who were a select group. Nevertheless, the study of Vaturi et al. (8) is useful; it confirms that even in the current era, and even in older patients with rheumatic mitral valve disease, AR and not AS is the more common lesion, and mild aortic valve disease (AVD) rarely progresses to severe AVD over a long follow-up period. Therefore, patients with mild AVD at time of surgery for rheumatic mitral valve disease should not have surgery for the AVD. CORONARY BYPASS SURGERY. In developed countries, rheumatic fever and rheumatic heart disease are uncommon, if not rare. Thus, the major clinical issue in these countries relates to the need for prophylactic AVR for mild AS at time of coronary bypass surgery (CBS). In 1994, Collins and Aranki (9) described 44 patients with previous CBS who subsequently had AVR (AS was mild to moderate at the time of CBS) and had a high operative mortality (19.2%) (Table 2). The study of Collins and Aranki (9) has served the useful purpose of drawing attention to the clinical problem of management of associated AVD. Subsequently, Odell et al. (10) and Fighali et al. (11) have also shown a higher operative mortality of 17% and 14%, respectively, for subsequent AVR (Table 2). In the study of Odell et al. (10), 30/145 (21%) patients also had other cardiac/vascular procedures in addition to repeat CBS at time of AVR. However, three subsequent studies of Fiore et al. (12), Hoff et al. (13), Sundt et al. (14), and their co-workers (Table 2) have failed to confirm these findings. Fiore et al. (12) showed the operative mortality in 28 patients for AVR subsequent to CBS was 18%, compared with 9.1% for initial CBS and AVR in 175 patients. The difference was not statistically significant, and the 10-year survival after AVR was also not significantly different. Hoff et al. (13) reported on 23 patients undergoing AVR subsequent to CBS; there was no hospital mortality, and the five-year actuarial survival after AVR was 71%. Sundt et al. (14) described 52 patients who had AVR subsequent to CBS; the hospital mortality was 7.7% compared with 6.3% (p NS) in 427 patients

2010 Rahimtoola JACC Vol. 33, No. 7, 1999 Editorial Comment June 1999:2009 15 Table 1. Outcome of Rheumatic AR in Young Patients Cumulative high-risk group Mortality at 6 years 30% Angina at 7 years 60% Heart failure at 6 years 60% Mortality or angina or heart failure at 6 years 87% Cumulative low-risk group Mortality at 6 years 0% at 15 years 5%* Angina at 5 years 2% Heart failure at 6 years 2% at 15 years 5% Mortality or angina or heart failure at 15 years 8% *The only patient (of the 72 patients) in this subgroup who died had developed two of the three risk factors described above. Patients were considered to be in a cumulative high-risk group if they had systolic blood pressure 140 mm Hg or diastolic blood pressure 40 mm Hg, moderate or marked left ventricular enlargement on chest x-ray and two of three ECG abnormalities (S in V 2 RinV 5 51 mm, ST segment depression or T wave inversion in left ventricular leads). Adapted from Spagnuolo et al. (7). undergoing simultaneous CBS and AVR. There is incomplete information about various parameters in most of the studies (9 14) (Table 2). The important issues to be considered in these studies include the following: 1. The studies described patients who had AVR after CBS. At the time of initial CBS, patients were said to have had mild/moderate AS or no AS (9 14). However, none of these studies provided any data on patients who had mild AS or no AS at time of initial CBS but who subsequently have not needed AVR (15). Pomerance documented from pathologic studies that calcification, thickening and other abnormalities of valves were common in older people (16). A subsequent echocardiographic/doppler study in the population showed that in people aged 55 to 71 years and 75 to 86 years, slight calcification of the aortic valve was present on echocardiography in 21% and 43%, respectively, and severe calcification was present in 7% and 14%, respectively (17). Thus, it seems plausible that the number of patients in the studies who required subsequent AVR (9 14) is a very small fraction of those who can be expected to have had aortic valve calcification, and thus, AVD at time of initial CBS. 2. The number of patients who needed AVR after CBS was quite small. For example, in the Collins study (9), 22 patients who initially had CBS at their own institution needed AVR over a period of 17 years, which averages 1.3 patients per year. Overall, it seems that at each of these institutions, about two to four patients each year had AVR following CBS, which is a very small number compared with the total umber of patients undergoing isolated CBS or even combined CBS and AVR. 3. There is a price to be paid for performing AVR for mild AS at time of CBS. This includes a higher operative mortality for combined CBS and AVR (approximately a doubling of operative mortality as compared to isolated CBS) (9), and late mortality (up to approximately 2% to 4%/year) (18,19) and morbidity including reoperation for prosthetic valve malfunction (up to approximately 2% to 6%/year) (18,19). The average time from initial CBS to subsequent AVR in the cited studies was about eight years (Table 2) (9 14). Table 2. Data on Patients Who Had AVR Subsequent to CBS Collins et al. (9) 1994 Odell et al. (10) 1996 Fighali et al. (11) 1995 Fiore et al. (12) 1996 Hoff et al. (13) 1996 Sundt III (14) 1997 Total no. of patients 44 145 104 28 23 52 Years of study 1975 92 1975 94 1983 93 1980 94 1986 95 1985 96 Time: CBS to AVR (yrs) 8 164 mo. (68) 9.0 3 8 4 2 17 (7.6) 7.8 4.0 At time of AVR Age, yrs 52 83 (73) 71 7.6 67 9 70.4 9.1 56 85 (69) 72.9 6.2 Angina 38% 66% Avg. Class 1.7 100% Heart failure 24% 9% 70% Heart failure angina 36% NYHA: FC III IV 76% 59% Avg. Class 2.7 53% LV dysfunction 53% Score 8.3 3.8 78% Repeat CBS 50% 46% 57% 75% 50% Op. mortality 18.2% 17% 14% 18% None (0%) 7.7% Post op. Myocardial infarction 14% 1.1% 4% 1.9% Heart failure YES None Low cardiac output YES 8.7% 9% 15% Significant complications 45%?56% 61% 22% Causes of death Low cardiac CO 75% Combined 12% 100% Sudden death 25% 80% Data not stated; avg. average; CO cardiac output; op. operation.

JACC Vol. 33, No. 7, 1999 June 1999:2009 15 Rahimtoola Editorial Comment 2011 4. At subsequent AVR, 46% to 75% of the patients needed repeat CBS. Thus, if the patients initially had CBS and AVR, about 50% (Table 2) would presumably have needed reoperation anyway for graft atherosclerosis, progression of native CAD or both. 5. Many of the centers in the cited studies are referral centers. In two studies, 50% (9) and 43% (10) of the patients had their initial CBS elsewhere. Thus, the initial evaluation of AS and subsequent follow up presumably also occurred elsewhere. A large number of patients at time of subsequent AVR had heart failure, were in NYHA Functional classes III and IV and had reduced LV ejection fraction (9 14). Would a more careful follow up and earlier appropriate therapy have reduced these and other adverse factors and thus lowered the subsequent hospital mortality for the AVR? Will the operative mortality of AVR subsequent to CBS be lower in the late 1990s? 6. The assessment of severity of AS was not uniform (9 14). Is it possible that the assessment of the severity of AS at time of initial CBS and also at time of subsequent AVR may have been incorrect? For example, in one study, the aortic valve area (AVA) at time of initial CBS averaged 1.05 cm 2 (12), and some patients needed subsequent AVR within two months. In another study, the AVA at initial CBS was as low as 0.9 cm 2, and patients needed subsequent AVR within eight months (9). Thus, it is probable that in some patients severity of AS was not correctly diagnosed and AVR should have been performed at time of initial CBS. At the time of subsequent AVR, in one study the only symptom was angina in 38%, the AVA was up to 1.7 cm 2 and 50% of the patients needed repeat CBS (9), and the AS was graded as mild to moderate. In another study, all patients had angina, aortic valve gradient (were the gradients mean or peak?) was 36 27 mm Hg (some must have had very small gradients), and vein grafts demonstrated angiographic disease and vein grafts 7 to 10 years old were routinely replaced (14). Thus, it is probable that at time of subsequent AVR, some patients had mild AS, and angina was due to progression of CAD/graft atherosclerosis. 7. A careful review is needed to learn what is meant by no AS, the limitations of gradients obtained by Doppler ultrasound and the assessment of severity of AS by gradients, what criteria should be used to grade severity of AS and the progression of severity of AS. In some studies, patients were graded as having no AS or no abnormality of the aortic valve at time of initial CBS, but the criteria used to make these diagnoses were not provided (14). Patients who have an ejection systolic murmur across the LV outflow tract may have a normal valve, a thickened valve or calcified valve or a stenotic valve. One needs to distinguish these three conditions. An aortic valve may be diseased but the orifice of the aortic valve has to be narrowed by up to approximately 50% before a measurable pressure gradient is present (20) when pressure gradients are directly measured. Thus, the presence of no gradient or a small gradient does not mean the valve is not stenotic. In one prospective study, the diagnosis of aortic sclerosis (a subjective evaluation) and of AS by echocardiography/ Doppler could not be confirmed on re-analysis in 27% and 20%, respectively (21). Thus, one has to be very careful about the diagnosis of no AS in patients with diseased valves. In several studies, the severity of AS was assessed by echocardiography and Doppler ultrasound. It must be remembered that None of the echocardiographic techniques measures intravascular pressure directly (21). The formula used for aortic valve gradient (AVG) is P 4v 2, which is a simplification of the Bernoulli equation (21): 1 2 p v 2 2 P 1 P 2 Convective Acceleration p 2 2 DV/DT DS Flow Acceleration R V Viscous Friction Several assumptions are made to calculate valve gradient by Doppler ultrasound. These include eliminating the flow acceleration and viscous friction factors, and ignoring the proximal velocity (22), and that energy losses, nonuniform velocity profiles, unsteady flow and omission of the upstream velocity also affect the accuracy of Doppler assessments of pressure drop (23). Gradients obtained by Doppler estimate gradients at the level of the valve whereas gradients obtained a few centimeters distal to the aortic valve after pressure recovery has occurred are more meaningful for the circulation (24). Doppler gradients are liable to be incorrect in patients with high cardiac output and in those with small annuli and eccentric orifices (23). The latter two conditions occur frequently in older patients ( 60 years), especially if the stenosis is judged to be moderate (23). In the cited studies at the time of CBS, the patients were in their sixties (Table 2). The gradient across an aortic valve is related to flow across the valve in systole and is a per beat, and not a per minute, function (25). Thus, AVG is related to forward stroke volume from the LV and to systolic ejection time both of which are a function of heart rate, and of LV preload, afterload and myocardial contractility (3,26,27). In addition, because of two obstructions in-series (stenotic aortic valve and systemic arterial resistance), the gradient is also influenced by systolic pressure proximal to the distal stenosis, that is, in the ascending aorta. Thus, AVGs, no matter how they are obtained, may change within minutes and do decrease over months of follow-up (Fig. 1). Otto et al. (28) have documented that AVG may not even increase when the AV stenosis worsens. In 636 patients studied by cardiac catheterization over a 10-year period, no AVG (peak or mean) was found that was both sensitive and specific for severe AS. A mean gradient of 50 mm Hg or a peak gradient of 60 mm Hg were specific with a 90% or more positive predictive value.

2012 Rahimtoola JACC Vol. 33, No. 7, 1999 Editorial Comment June 1999:2009 15 Table 3. Suggested Grading of the Degree of Aortic Stenosis Aortic Stenosis AVA (cm 2 ) AVA Index (cm 2 /m 2 ) Mild 1.5 0.9 Moderate 1.0 to 1.5 0.6 to 0.9 Severe* 1.0 0.6 *Patients with an aortic valve area that is at a borderline value between the moderate and severe grades (0.9 to 1.1 cm 2 ; 0.55 to 0.65 cm 2 /m 2 ) should be individually considered for reasons discussed in the text. The AVA index was calculated on basis of an average BSA of 1.75 m 2. Criteria for AVA derived from natural history studies after cardiac catheterization. Reproduced with permission from Rahimtoola (55). Figure 1. Change in mean aortic gradient (MG) versus interval of follow up. The r value of the regression equation was 0.40 after excluding one outliner. In some patients, the follow-up was about 60 to 90 days. Many patients had a reduced gradient at follow up, and at 1,000 days, the change in gradient ranged from about 50% to 200%; at about 750 days the change in gradient was almost 100%. Reproduced with permission from Brener et al. (42). However, it was not possible to find a lower limit with 90% negative predictive value. The authors emphasized the importance of measuring AVA in all patients with suspicion of severe AS with cardiac catheterization gradients mean of 50 mm Hg (present in 50% of patients in their study) and peak of 60 mm Hg (present in 47% of patients in their study) (29). Peak gradient by Doppler ultrasound measures velocity of blood flow in the earliest part of systolic ejection at a time which may not necessarily be associated with peak blood flow in AS. In the normal heart, the dynamics of LV ejection are primarily inertial in character (not resistive) and the major phenomenon relating pressure and flow in the ascending aorta is that governing mass acceleration (30). If mass acceleration, and thus, velocity of blood flow is increased, a systolic gradient in early systole can be documented in normal hearts, both in animals (30) and in humans (31). Furthermore, these early systolic gradients can be markedly increased with inotropic stimulation in normal hearts both in experimental animals (32) and in humans (31). Peak gradients calculated from Doppler recordings occur in early systole, which may thus not be related to valve stenosis or may be exaggerated by valve stenosis. Therefore, it is better to measure mean AVG. The stenotic valve area is inversely related not to the mean AVG but to the square root of the mean AVG. The 95% confidence interval of Doppler mean AVG to that obtained by simultaneous gradient at cardiac catheterization is 20 mm Hg (26,27,33). Therefore, a suggested grading of severity of AS by gradient obtained by Doppler ultrasound is that (26,27): AS is highly likely to be severe if the peak gradient is 80 and mean gradient is 70 mm Hg, AS is probably severe if peak gradient is 60 to 79 and mean gradient is 50 to 69 mm Hg and the AS severity is uncertain if peak gradient is 60 and mean gradient is 50 mm Hg (26,27,29). The severity of AS can be graded on the basis of AVA obtained at cardiac catheterization and the subsequent natural history data on follow-up. These are extensively referenced in the cited review (Table 3) (26,27). The calculation of AVA by the method of Gorlin and Gorlin (34) was criticized 45 years ago (35), but it is still widely used, is clinically useful and has stood the test of time (26,27). Progression of severity of AS has been cited as an issue that should be considered for recommending AVR at time of initial CBS. Progression has been assessed by changes in pressure gradients and AVA. The pressure gradient is said to increase by 10 to 15 mm Hg/year (28,36 43). In some patients it increases by as much as 15 to 19 mm Hg/year, while others show little or no change or even an actual decrease (Fig. 1). AVAs are said to decrease by 0.1 to 0.3 cm 2 /year (42 46) and the average rate of change has ranged from 0.10 to 0.15 cm 2 /year. The 95% confidence limit of Echocardiographic-Doppler derived AVA to that obtained by cardiac catheterization ranges from 0.4 to 0.8 cm 2 (26,27). A small AVA by Doppler ultrasound may result partly from measured small LV outflow tract, which can lead to an erroneous overestimation of the severity of AS (17). Moreover, Otto et al. (28) have documented that although stenosis severity progresses more rapidly in patients who develop symptoms requiring AVR, these patients cannot be identified at the initial study. There are problems with the evaluations of progression of severity of AS. Progression of AS is not uniform in all age groups, it is more rapid in older patients and in those with calcific ( degenerative ) AS (46). In the studies that had repeat cardiac catheterization to assess progression of AS, (38,40,42,44 47) there presumably had to be a clinical reason to repeat the cardiac catheterization. In most of the echo-doppler studies, the data were obtained from a retrospective review of patient records rather than as a prospective study of consecutive unselected patients. The follow-up study in some patients has been as little as two to three months, (42) (Fig. 1) 3, (43) 4, (46) 6, (28,40) 7, (38) 11, (41) 12 (39) and 13 (36) months and the initial change in AVG/AVA were then extrapolated to calculate percent change per year (linearized rate). However, progression of

JACC Vol. 33, No. 7, 1999 June 1999:2009 15 Rahimtoola Editorial Comment 2013 Figure 2. A male patient aged 41 years had a heart murmur and aortic stenosis diagnosed at age 20 years. In 1985, he was asymptomatic, but from a cardiac point of view, he had the classic physical findings of mild AS. Since 1994; he has had clinical signs of moderate aortic stenosis. He has remained asymptomatic from a cardiac point of view but has symptoms related to his rheumatoid arthritis. He continues to work full time. Mean aortic valve gradients have ranged from 23 to 27 mm Hg, with peak gradients from 44 to 67 mm Hg. There was considerable variation in gradients throughout the follow-up evaluations. Aortic valve areas by echocardiography/doppler ultrasound from 1988 to 1998 are shown. Reduction of valve area appears to be more a stepwise function, and linear rate of progression varies markedly from.004 to 1.3 cm 2 /year, depending on the points chosen to calculate linear rate of progression. AS does not necessarily occur in a linear manner but usually in a stepwise manner (Fig. 2). Furthermore, depending on the time interval used to obtain the linearized rate, the rate of change can vary over a very wide range, for example, from 0.004 cm 2 /year to 1.3 cm 2 /year (Fig. 2). When an event does not occur in a linear or a reasonably linear manner and when follow-up is short ( 2 years) or very short (a few months), it is questionable whether events should be expressed as a linearized rate per year. One study concluded that aortic stenosis progresses predictably over time (42), which it does on average; the time to follow-up echocardiography/doppler ranged from about 30 to 90 days to up to 2,000 days (Mean 1,016 482 days) (Fig. 1). However, many patients had a lower gradient at follow-up and at approximately 1,000 days the percent change in mean aortic gradient in an individual patient ranged from about 50% to 200% (Fig. 1), and the r value for the relationship after excluding one outliner was only 0.40. If AVA actually decreases by 0.10 to 0.15 cm 2 /year, and if patients initially had a valve area of 1.6 cm 2, then within 10 years all such patients would be expected to have an AVA of 0.60 to 0.01 cm 2, which is unlikely. Moreover, the natural history study of Horstkotte and Loogen (48) showed that in 149 patients with initial AVA of 1.5 cm 2 by cardiac catheterization, 20 years later 63% of patients still had mild AS. This relatively benign natural history of mild AS ( 1.5 cm 2 ) is better than that of any valve replacement device/procedure currently available. The calculated rate of progression can be expected to vary and does vary with the initial AVA. In the cited studies, many patients already had severe AS at the initial study (28,37 41,46). For example, in one study, 69% of the patients had severe AS at the initial study (37), and in one prospective natural history study (43), the median AVA at entry into the study and at final follow-up at time of AVR/death was about 1.0 cm 2. That is, many patients already had severe AS at entry into the study. In brief, mild AS has a more benign outcome than valve replacement. Assessment of AVD and its severity is not without problems that must be recognized and taken into account. Performance of both noninvasive and invasive procedures, analyses of the data and overall evaluation of the patient should be done with care by skilled and experienced personnel. Clinical implications are as follows: 1. The severity of AS at the time of initial CBS should be carefully and accurately determined. 2. Patients with mild AS and no AS at time of CBS should not undergo AVR at time of initial CBS. 3. At time of initial CBS, it would be prudent to obtain an echocardiogram in all patients aged 55 to 60 years. If the valve is thickened, calcified, or is otherwise abnormal, the patients should have careful evaluation by skilled and experienced personnel of both their clinical status and of the valve. 4. After CBS, patients with valvular abnormality initially should be followed closely and carefully by appropriately experienced and skilled personnel for assessment of progression of AS and for evaluation of symptoms, heart failure and LV dysfunction. If any of these occur, patients must be treated promptly and appropriately. Patients must be treated aggressively for control of adverse factors for atherosclerosis which are common in such patients (21). Control of these risk factors is beneficial for slowing or delaying progression of atherosclerosis in native coronary vessels and grafts. These risk factors are common in older patients with calcific AS (17,21,43) and may have an etiologic relationship to the development of calcific AS in the older patient (21,49 53), either directly or as an autoimmune reaction to antigens present in the valve (49). Patients must stop smoking. Lipid abnormalities, hypertension and diabetes must be corrected, patients should take aspirin and appropriate hormone replacement therapy if indicated, provided there are no contraindications to their use. Regular exercise and attaining an ideal weight are also desirable, and on follow-up, one needs to carefully evaluate whether symptoms or abnormal findings are due to progression and development of severe AS or of atherosclerosis in the coronary arteries/grafts. 5. In clinical practice, the average rate of change of gradient and valve area is of very limited value. Patients must be individualized; they should be carefully evaluated and followed, particularly those in the older age group who

2014 Rahimtoola JACC Vol. 33, No. 7, 1999 Editorial Comment June 1999:2009 15 have mild calcific AS or have valve disease with no demonstrable gradient. ASCENDING AORTIC DISEASE. In patients with dissecting aneurysm of the ascending aorta, AR usually implies that the dissection has extended down to the aortic root/annulus. Thus, these patients need aortic valve surgery at time of surgery for the aneurysm even if the AR is mild (54). Moderate aortic valve disease. AORTIC REGURGITATION. With moderate AR, it may be difficult to maintain the patient on extracorporeal circulation or to wean them off bypass without AVR. This factor should be considered when recommending CBS. AORTIC STENOSIS. Patients with AVA from 1.0 to 1.5 cm 2 are considered to have moderate AS (Table 3). Older patients with calcific AS have more rapid progression of severity of AS. Thus, it may be clinically prudent to perform AVR at time of initial CBS in some older patients ( 60 years) with moderate calcific AS, especially if the AVA is from 1.0 to 1.3 cm 2 (from 0.60 to 0.75 cm 2 /m 2 ). However, once again, clinical judgment is important because in small persons, AVA from 1.0 to 1.5 cm 2 may actually be mild AS, and in large people, AVA in this range may actually be severe AS. In such patients, correcting AVA for body size is of some help in clinical decision making. Reprint requests and correspondence: Dr. S. H. Rahimtoola, Distinguished Professor, Division of Cardiology, University of Southern California, 2025 Zonal Avenue, Los Angeles, California 90033. REFERENCES 1. Rahimtoola SH. Aortic valve stenosis. In: Schlant R, Alexander RW, Eds. Hurst s The Heart (9th ed.). New York: McGraw-Hill, 1998: 1759 69. 2. Rahimtoola SH. Aortic valve regurgitation. In: Schlant R, Alexander RW, eds. Hurst s The Heart (9th ed.). New York: McGraw-Hill, 1998:1769 87. 3. 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