Figure 5.

Proposed schematic integrating multi-modality LV assessments in AS. The current paradigm remains one of aortic valve replacement when AS is severe and symptomatic, or if there is overt evidence of impaired LV function (reduced ejection fraction). Several randomised controlled trials are assessing early intervention in severe asymptomatic AS (orange box). Of these, only RECOVERY has been completed, demonstrating a clinical benefit with early intervention in a population with very severe AS, a large proportion of which were bicuspid. EVOLVED is the only trial utilising imaging to select a subset of asymptomatic patients for early intervention. The other trials assess if early intervention could be beneficial in this setting, regardless of adjunctive risk stratification tools. Echocardiography remains, and should remain, the first-line investigation to assess AS and its effect on the LV. However, CMR adds incremental information regarding subclinical myocardial disease (fibrosis) via tissue characterisation that cannot be detected with echocardiography; these pathological changes are often present before ejection fraction falls and have prognostic implications. Other indirect assessments of LV function in response to the fixed afterload induced by AS include exercise ECG and biomarkers such as BNP. AS, aortic stenosis; BNP, B-type natriuretic peptide; CMR, cardiac magnetic resonance; RECOVERY, Randomized Comparison of Early Surgery Versus Conventional Treatment in Very Severe Aortic Stenosis, EVOLVED, Early Valve Replacement Guided by Biomarkers of LV Decompensation in Asymptomatic Patients with Severe AS; GLS, global longitudinal strain; LV, left ventricular.