Multi-modality imaging in aortic stenosis: an EACVI clinical consensus document

Abstract

In this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk-stratification and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. CT is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose, however contrast computed tomography techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance and computed tomography will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this disease.

Myocardial sodium–glucose cotransporter 2 expression and cardiac remodelling in patients with severe aortic stenosis: The BIO‐AS study

“…Aortic stenosis was defined according to the latest European Society of Cardiology guidelines. 2,18 HG AS was defined as peak transvalvular velocity ≥4 m/s, transvalvular mean gradient (MG) ≥40 mmHg, and aortic valve area (AVA) ≤1 cm 2 in a regular flow state (LV ejection fraction [LVEF] >50% and stroke volume index ≥35 ml/m 2 ). LF-LG AS was defined as AVA ≤1 cm 2 , but MG <40 mmHg and peak transvalvular velocity <4 m/s in a low flow state (stroke volume index <35 ml/m 2 ).…”

“…In patients with LF-LG AS, severity was confirmed with low-dose dobutamine stress echocardiography and/or cardiac computed tomography, as appropriate. 2,18 The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II estimated the mortality risk after cardiac surgery. Patients were referred for AVR based on the current guidelines.…”

Diagnostic Contexts of Echocardiographic Nonapical Window

“…In this setting, the RPA prevented the need for further diagnostic exams (ie, computed tomography for calcium score or stress echocardiography) to clarify the AS severity grade. 11 …”

Moderate aortic stenosis: Navigating the uncharted

“…Multimodality imaging significantly enhances the evaluation of moderate AS, offering detailed insights into the condition of the valve, the aorta, and the myocardium. 13 The multimodal integrative approach enables the staging of the extent of cardiac damage beyond the aortic valve, the detection of replacement and diffuse interstitial fibrosis, the assessment of concomitant cardiac amyloidosis, and the measurement of valve calcification activity. By leveraging anatomical, functional, structural, and metabolic data from different imaging modalities, we glean a unique opportunity to phenotype patients with AS in exquisite detail and obtain powerful information to improve our understanding of the underlying pathophysiology.…”

“…10 To enhance risk stratification and management of patients with moderate AS, a deeper understanding of its definition, pathophysiology, and the interaction between the aortic valve and LV is essential. This review navigates the uncharted aspects of diagnosing and managing moderate AS, addressing the challenges of inconsistent grading, discussing the role of multimodality cardiovascular imaging for staging the extent of extra aortic valve cardiac damage [11][12][13] and heart failure associated with AS and improving risk stratification. Furthermore, we will examine the potential impact of ongoing trials in the future management of moderate AS.…”