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Background: About 15–20% of patients with severe aortic stenosis (AS) (aortic valve area, AVA ≤ 1 cm2) have a low transvalvular flow and a low mean gradient despite preserved left ventricular ejection fraction (LVEF). This entity, named paradoxical low flow, low gradient (PLFLG) AS, was initially described using Doppler-echocardiography. However, some concerns were raised about potential overestimation of its prevalence by echo. Aim was to describe the prevalence and characteristics of patients with PLFLG AS using cardiac catheterization.Methods and Results: Between 1994 and 2010, 2005 patients underwent cardiac catheterization for evaluation of AS severity and identification of coronary artery disease prior to aortic valve replacement (AVR). Of these, we excluded those with other valvular heart disease or with LVEF < 50%. Of the remaining 1296 pts, 58% of patients had an AVA≤ 1 cm2 and a mean gradient >40mm Hg (classical severe AS), whereas 23% had an AVA≤ 1 cm2 but a mean gradient <40mm Hg; In comparison to patients with Classical severe AS (table), those with PLFLG AS were significantly older, more often female, had lower cardiac output, higher systolic blood pressure, and pulmonary vascular resistance. The % of patients who finally underwent AVR was lower (85 vs. 95%) and that of patients who had concomitant CABG was higher (38 vs. 31%) in patients with PLFLG AS.Conclusion: This study shows PLFLG severe AS is a frequent entity with up to 23% of patients with severe AS referred to AVR. These patients had more frequent co-morbidities.These findings further underlines the importance to correctly identify this entity so we do not deny surgery to patients with a small AVA and a low gradient despite preserved LVEF.