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Purpose of Review <p>This review explores evolving paradigms in aortic stenosis (AS) management, proposing a shift from fixed echocardiographic cutoffs to a continuum-based, multimodal imaging-guided approach.</p> Recent Findings <p>Traditional thresholds for severe AS (aortic valve area [AVA] &lt; 1.0&#xa0;cm², peak velocity ≥ 4.0&#xa0;m/s, mean gradient ≥ 40 mmHg) do not adequately account for flow dynamics, sex-based differences, or advances in imaging. Adjusting the AVA to 1.1–1.2&#xa0;cm² and adopting modality-specific thresholds for computed tomography (CT) and cardiac magnetic resonance (CMR) improves assessment accuracy. The stroke volume index (SVi) cutoff of 35&#xa0;ml/m² appears arbitrary, suggesting the need for individualised parameters. Likewise, a left ventricular ejection fraction (LVEF) threshold of 50% may be insufficient, as elevated mortality has been observed in those with LVEF between 50 and 59%. Left ventricular hypertrophy (LVH) varies by sex and is not consistently present in severe AS. Myocardial fibrosis is prognostically significant—diffuse fibrosis may regress post-intervention, but mid-wall fibrosis is typically irreversible. Staging of cardiac damage offers valuable prognostic insight, with outcomes worsening as damage progresses. Calcium scoring supports diagnosis but underestimates fibrotic burden; a low score does not exclude severe disease. Early intervention in asymptomatic severe AS is increasingly supported. Moderate AS should not be underestimated, as it carries a significant risk of increased mortality, particularly among symptomatic patients and those with left ventricular dysfunction. Comorbidities such as coronary microvascular dysfunction and cardiac amyloidosis further worsen outcomes. Recent studies also suggest a potential role for sodium-glucose cotransporter-2 (SGLT2) inhibitors in altering progression and outcome.</p> Summary <p>An integrated, personalised approach incorporating multimodal imaging is essential to redefining AS severity and optimising timing of intervention.</p>

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Aortic Stenosis: Challenges, Innovations, and the Path Forward

  • 期刊论文

  • 发表日期：

    2025年10月11日

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  • Muntasir Abo Al Hayja,
  • Mohammed Al-Tawil,
  • Amer Harky,
  • Mohamed Zeinah,
  • Sobhan Vinjamuri

摘要

Purpose of Review

This review explores evolving paradigms in aortic stenosis (AS) management, proposing a shift from fixed echocardiographic cutoffs to a continuum-based, multimodal imaging-guided approach.

Recent Findings

Traditional thresholds for severe AS (aortic valve area [AVA] < 1.0 cm², peak velocity ≥ 4.0 m/s, mean gradient ≥ 40 mmHg) do not adequately account for flow dynamics, sex-based differences, or advances in imaging. Adjusting the AVA to 1.1–1.2 cm² and adopting modality-specific thresholds for computed tomography (CT) and cardiac magnetic resonance (CMR) improves assessment accuracy. The stroke volume index (SVi) cutoff of 35 ml/m² appears arbitrary, suggesting the need for individualised parameters. Likewise, a left ventricular ejection fraction (LVEF) threshold of 50% may be insufficient, as elevated mortality has been observed in those with LVEF between 50 and 59%. Left ventricular hypertrophy (LVH) varies by sex and is not consistently present in severe AS. Myocardial fibrosis is prognostically significant—diffuse fibrosis may regress post-intervention, but mid-wall fibrosis is typically irreversible. Staging of cardiac damage offers valuable prognostic insight, with outcomes worsening as damage progresses. Calcium scoring supports diagnosis but underestimates fibrotic burden; a low score does not exclude severe disease. Early intervention in asymptomatic severe AS is increasingly supported. Moderate AS should not be underestimated, as it carries a significant risk of increased mortality, particularly among symptomatic patients and those with left ventricular dysfunction. Comorbidities such as coronary microvascular dysfunction and cardiac amyloidosis further worsen outcomes. Recent studies also suggest a potential role for sodium-glucose cotransporter-2 (SGLT2) inhibitors in altering progression and outcome.

Summary

An integrated, personalised approach incorporating multimodal imaging is essential to redefining AS severity and optimising timing of intervention.