Abstract
Aortic stenosis (AS) is the most frequent degenerative valvular disease in developed countries. Its incidence has been constantly rising due to population aging. The diagnosis of AS was considered straightforward for a very long time. High gradients and reduced aortic valve area were considered as “sine qua non” in diagnosis of AS until a growing body of evidence showed that patients with low gradients could also have severe AS with the same or even worse outcome. This completely changed the paradigm of AS diagnosis and involved large numbers of parameters that had never been used in the evaluation of AS severity. Low gradient AS patients may present with heart failure (HF) with preserved or reduced left ventricular ejection fraction (LVEF), associated with changes in cardiac output and flow across the aortic valve. These patients with low-flow low-gradient or paradoxical low-flow low-gradient AS are particularly challenging to diagnose, and cardiac output and flow across the aortic valve have become the most relevant parameters in evaluation of AS, besides gradients and aortic valve area. The introduction of other imaging modalities in the diagnosis of AS significantly improved our knowledge about cardiac mechanics, tissue characterization of myocardium, calcium and inflammation burden of the aortic valve, and their impact on severity, progression and prognosis of AS, not only in symptomatic but also in asymptomatic patients. However, a variety of novel parameters also brought uncertainty regarding the clinical relevance of these indices, as well as the necessity for their validation in everyday practice. The aim of this review is to summarize the prevalence of HF in patients with severe AS and elaborate on the diagnostic challenges and advantages of comprehensive multimodality cardiac imaging to identify the patients that may benefit from surgical or transcatheter aortic valve replacement, as well as parameters that may help during follow-up.
Highlights
Aortic stenosis (AS) together with mitral regurgitation represents the most frequent valvular heart disease in the Western world [1]
This study demonstrated that projected aortic valve area (AVA), a flow-standardized effective orifice area (EOA), provides incremental and superior diagnostic and prognostic information [23]
The assessment of AS severity in patients with heart failure (HF) is challenging, but nowadays the multimodality cardiac imaging approach provides a comprehensive evaluation of all anatomical and functional features of the aortic valve, and of the myocardium, which is significantly impaired in patients with HF
Summary
Aortic stenosis (AS) together with mitral regurgitation represents the most frequent valvular heart disease in the Western world [1]. LVH eventually induces elevation of LV filling pressure that is retrogradely transferred to pulmonary circulation, causing dyspnea and cardiac pulmonary oedema in AS patients, even in conditions of preserved LV ejection fraction (LVEF) [2] These patients are obviously developing an entity known as heart failure with preserved ejection fraction (HFpEF). The long-term prognosis in patients with these new entities, with low-flow low-gradient and paradoxical low-flow low-gradient AS, has not been fully understood so far This clinical review will summarize the current evidence about the multimodality imaging techniques and parameters that are used in diagnosis and prognosis of patients with severe AS and HF (HFpEF and HFrEF), as well as the strengths and weaknesses of these methods in everyday clinical circumstances
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