The elusive goal for decades has been to identify factors, which, if identified early, would improve surgical outcomes. Many investigators have studied the natural history of AS, and its consequences: LVH, myocardial fibrosis, and LV diastolic dysfunction ((2),(3),(10),(11),12). LV systolic dysfunction is often more subtle; it can be difficult to differentiate myocardial contractile failure from so-called afterload mismatch. Factors that correlate with poor prognosis include the degree of valve calcium, high gradient, LV mass index, and concentric remodeling ((10),(11),(12),(13),14). More recently the degree of LV longitudinal shortening, B-type natriuretic peptide levels, flow/gradient ratios, and myocardial fibrosis using magnetic resonance imaging have all been studied as prognostic indicators with the hope of better defining and refining surgical indications ((14),(15),(16),(17),(18),19). Many physicians have erroneously equated normal left ventricular ejection fraction (LVEF) with normal output/flow. Hachicha et al. brought to attention the fact that patients with low gradients due to low flow (despite preserved LVEF) may not, because of their low gradients, be recognized as having severe AS (20). Pibarot and Dumesnil emphasized the interrelation between valvular, ventricular, and arterial variables in newer approaches to assessing disease severity (21).