Aortic valve hemodynamics in atrial fibrillation: Should the highest Doppler signal be used to estimate severity of aortic stenosis?

Grading severity of AS in AF is complicated by varying stroke volumes associated with fluctuating maximum velocities and pressure gradients across the aortic valve. Current guidelines recommend averaging five continuous-wave peak velocity and mean gradient (MG) Doppler signals across the aortic valve when estimating severity of AS in AF. However, it is unknown when grading severity of AS how the average of multiple Doppler signals vs the highest Doppler signal in AF compares to the Doppler signals when the patient is in normal sinus rhythm. We present a series of patients with AS who had two echocardiograms performed within 2-4 months of each other, one when in normal sinus rhythm and one when in AF, and compare the aortic valve hemodynamics associated with the two rhythms.