Over many decades the ability to identify and treat patients with severe aortic valve stenosis (AS) has changed. In the late 1940s and early 1950s the diagnosis of severe aortic stenosis was met with ambiguity and associated with certain demise in young patients born with bicuspid aortic valves or patients with rheumatic heart disease. Medical therapy did not change outcomes and percutaneous intervention was not in existence. Surgical techniques to alter the aortic valve by way of commissurotomy served as the basis for early surgical intervention in patients with rheumatic aortic stenosis [1] . Freeing the leaflets from commissural fusion was successful for those with rheumatic heart disease but for those with the “arteriosclerotic form of aortic stenosis in which the leaflets are hardened by calcium salts seem to be most inappropriate or even impossible” to treat with this surgical technique [1] .The invention of the heart and lung machine allowed surgical valve replacement to be considered. By 1960 mechanical aortic valves were being placed surgically but operative risk was not trivial. Patients with progressive worsening aortic stenosis were followed and the natural history defined by Drs. John Ross and Eugene Braunwald [2] . Their early experience was dominated by patients with rheumatic heart disease but their observations serve as the basis of our teaching today. Patients seem to do well until a point when the forces on the left ventricle and surrounding structures became insurmountable with secondary hypertrophy leading to chest pain from subendocardial ischemia, syncope from a decrease in cerebral perfusion, or at worst heart failure. In time, patients not likely to survive surgery were referred for balloon aortic valvuloplasty to try and reduce the load on the left ventricle and improve survival. A procedure made popular by Dr. Alan Cribier in the late 1980s [3] . Deciding when to send someone for surgery in the setting of the substantial risks associated with the procedure became the nuanced pivotal decision for the physicians of the time. Waiting too long “when myocardial changes had become irreversible” only increased the operative mortality and thus the search for the “sweet spot” was at hand [2] .