In recent years, a subset of patients with low-gradient aortic stenosis (AS) has been recognized: patients having lowgradient severe AS, but preserved left ventricle ejection fraction (pEF)[1, 2]. This entity has been termed paradoxical, because of the unexpected low stroke volume despite a preserved EF. This paradox is probably related to a severe concentric hypertrophy of the left ventricle (LV), with small LV cavity and intrinsic myocardial contractile and diastolic dysfunction [2]. Although we already know that this subset has a poor prognosis, the identification of patients who would benefit from intervention remains an area of research needing improvement [1].

This diagnosis should be evoked when the aortic maximal velocity is under 4 m/s (mean pressure gradient< 40 mmHg), and the aortic valve area (AVA)≤ 1.0 cm2, stroke volume index (SVi)< 35 mL/m2 and LVEF≥ 50%[1, 2]. This is rather a rare occurrence and the first step in the diagnostic approach is to ascertain that all data is collected and interpreted in a correct manner, including performing the echocardiographic study in a moment when the patient’s blood pressure is well controlled. Moreover, the true severity of the valvular stenosis (an AVA index≤ 0.6 cm2/m2) should be ascertained [3]. A careful assessment of the overall clinical picture including comorbidities, clinical examination and multi-modality testing (eg laboratory testing, pulmonary function testing, coronary angiography, thoracic computed tomography….) should exclude other convincing explanations of symptoms. Furthermore, elevated natriuretic peptides and high aortic root calcification by CT may confirm AS severity [1, 2]. Aortic valve intervention (AVI) appears