Multimodality Imaging Assessment of Aortic Stenosis

  • Raluca Dulgheru
  • Patrizio LancellottiEmail author


Transthoracic echocardiography remains the key exam in the assessment of patients with AS, both for diagnostic and for treatment planning purposes. However, due to recent advances in multi-modality imaging in patients with AS, techniques such as cardiac CT, CMR, PET-CT become more and more important in severity grading of AS in patients with discordant findings at echocardiography, as well as in the risk stratification of asymptomatic patients and treatment planning of challenging cases. This chapter will highlight the role of multimodality imaging in patients with AS.


Aortic stenosis Multimodality imaging Echocardiography 


  1. 1.
    Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10:1–25.CrossRefGoogle Scholar
  2. 2.
    Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;63:2438–88.CrossRefGoogle Scholar
  3. 3.
    Minners J, Allgeier M, Gohlke-Baerwolf C, et al. Inconsistencies of echocardiographic criteria for the grading of aortic valve stenosis. Eur Heart J. 2008;29:1043–8.CrossRefGoogle Scholar
  4. 4.
    Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P. Paradoxical low flow, low gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation. 2007;115:2856–64.CrossRefGoogle Scholar
  5. 5.
    Lancellotti P, Magne J, Donal E, et al. Clinical outcome in asymptomatic severe aortic stenosis: insights from the new proposed aortic stenosis grading classification. J Am Coll Cardiol. 2012;59:235–43.CrossRefGoogle Scholar
  6. 6.
    Eleid MF, Sorajja P, Michelena HI, et al. Survival by stroke volume index in patients with low-gradient normal EF severe aortic stenosis. Heart. 2014.Google Scholar
  7. 7.
    Pibarot P, Dumesnil JG. Improving assessment of aortic stenosis. J Am Coll Cardiol. 2012;60:169–80.CrossRefGoogle Scholar
  8. 8.
    Carabello BA. Aortic stenosis. N Engl J Med. 2002;346:677–82.CrossRefGoogle Scholar
  9. 9.
    Pai RG, Varadarajan P, Razzouk A. Survival benefit of aortic valve replacement in patients with severe aortic stenosis with low ejection fraction and low gradient with normal ejection fraction. Ann Thorac Surg. 2008;86:1781–9.CrossRefGoogle Scholar
  10. 10.
    Barasch E, Fan D, Chukwu EO, et al. Severe isolated aortic stenosis with normal left ventricular systolic function and low transvalvular gradients: pathophysiologic and prognostic insights. J Heart Valve Dis. 2008;17:81–8.PubMedGoogle Scholar
  11. 11.
    Dumesnil JG, Pibarot P, Carabello B. Paradoxical low flow and/or low gradient severe aortic stenosis despite preserved left ventricular ejection fraction: implications for diagnosis and treatment. Eur Heart J. 2010;31:281–9.CrossRefGoogle Scholar
  12. 12.
    Herrmann HC, Pibarot P, Hueter I, et al. Predictors of mortality and outcomes of therapy in low-flow severe aortic stenosis: a Placement of Aortic Transcatheter Valves (PARTNER) trial analysis. Circulation. 2013;127:2316–26.CrossRefGoogle Scholar
  13. 13.
    Clavel MA, Dumesnil JG, Capoulade R, et al. Outcome of patients with aortic stenosis, small valve area, and low-flow, low-gradient despite preserved left ventricular ejection fraction. J Am Coll Cardiol. 2012;60:1259–67.CrossRefGoogle Scholar
  14. 14.
    Mohty D, Magne J, Deltreuil M, et al. Outcome and impact of surgery in paradoxical low-flow, low-gradient severe aortic stenosis and preserved left ventricular ejection fraction: a cardiac catheterization study. Circulation. 2013;128:S235–42.CrossRefGoogle Scholar
  15. 15.
    Eleid MF, Sorajja P, Michelena HI, et al. Flow-gradient patterns in severe aortic stenosis with preserved ejection fraction: clinical characteristics and predictors of survival. Circulation. 2013;128:1781–9.CrossRefGoogle Scholar
  16. 16.
    Briand M, Dumesnil JG, Kadem L, et al. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment. J Am Coll Cardiol. 2005;46:291–8.CrossRefGoogle Scholar
  17. 17.
    Hachicha Z, Dumesnil JG, Pibarot P. Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis. J Am Coll Cardiol. 2009;54:1003–11.CrossRefGoogle Scholar
  18. 18.
    Lancellotti P, Donal E, Magne J, et al. Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay. Heart. 2010;96:1364–71.CrossRefGoogle Scholar
  19. 19.
    Baumgartner H, Steffenelli T, Niederberger J, Schima H, Maurer G. “Overestimation” of catheter gradients by Doppler ultrasound in patients with aortic stenosis: a predictable manifestation of pressure recovery. J Am Coll Cardiol. 1999;33:1655–61.CrossRefGoogle Scholar
  20. 20.
    Carroll JD, Carroll EP, Feldman T, et al. Sex-associated differences in left ventricular function in aortic stenosis of the elderly. Circulation. 1992;86:1099–107.CrossRefGoogle Scholar
  21. 21.
    Page A, Dumesnil JG, Clavel MA, et al. Metabolic syndrome is associated with more pronounced impairment of left ventricle geometry and function in patients with calcific aortic stenosis: a substudy of the ASTRONOMER (Aortic Stenosis Progression Observation Measuring Effects of Rosuvastatin). J Am Coll Cardiol. 2010;55:1867–74.CrossRefGoogle Scholar
  22. 22.
    Lund BP, Gohlke-Barwolf C, Cramariuc D, et al. Effect of obesity on left ventricular mass and systolic function in patients with asymptomatic aortic stenosis (a Simvastatin Ezetimibe in Aortic Stenosis [SEAS] substudy). Am J Cardiol. 2010;105:1456–60.CrossRefGoogle Scholar
  23. 23.
    Cramariuc D, Cioffi G, Rieck AE, et al. Low-flow aortic stenosis in asymptomatic patients: valvular-arterial impedance and systolic function from the SEAS Substudy. JACC Cardiovasc Imaging. 2009;2:390–9.CrossRefGoogle Scholar
  24. 24.
    Cioffi G, Faggiano P, Vizzardi E, et al. Prognostic effect of inappropriately high left ventricular mass in asymptomatic severe aortic stenosis. Heart. 2011;97:301–7.CrossRefGoogle Scholar
  25. 25.
    Orsinelli DA, Aurigemma GP, Battista S, Krendel S, Gaasch WH. Left ventricular hypertrophy and mortality after aortic valve replacement for aortic stenosis. A high risk subgroup identified by preoperative relative wall thickness. J Am Coll Cardiol. 1993;22:1679–83.CrossRefGoogle Scholar
  26. 26.
    Eleid MF, Nishimura RA, Sorajja P, Borlaug BA. Systemic hypertension in low-gradient severe aortic stenosis with preserved ejection fraction. Circulation. 2013;128:1349–53.CrossRefGoogle Scholar
  27. 27.
    Kodali SK, Williams MR, Smith CR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med. 2012;366:1686–95.CrossRefGoogle Scholar
  28. 28.
    Altiok E, Koos R, Schroder J, et al. Comparison of two-dimensional and three-dimensional imaging techniques for measurement of aortic annulus diameters before transcatheter aortic valve implantation. Heart. 2011;97:1578–84.CrossRefGoogle Scholar
  29. 29.
    de Filippi CR, Willett DL, Brickner E, et al. Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low transvalvular gradients. Am J Cardiol. 1995;75:191–4.CrossRefGoogle Scholar
  30. 30.
    Fougeres E, Tribouilloy C, Monchi M, et al. Outcomes of pseudo-severe aortic stenosis under conservative treatment. Eur Heart J. 2012;33:2426–33.CrossRefGoogle Scholar
  31. 31.
    Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg. 2012;42:S1–44.CrossRefGoogle Scholar
  32. 32.
    Blais C, Burwash IG, Mundigler G, et al. The projected valve area at normal flow rate improves the assessment of stenosis severity in patients with low flow aortic stenosis: the multicenter TOPAS (Truly or Pseudo Severe Aortic Stenosis) study. Circulation. 2006;113:711–21.CrossRefGoogle Scholar
  33. 33.
    Clavel MA, Burwash IG, Mundigler G, et al. Validation of conventional and simplified methods to calculate projected valve area at normal flow rate in patients with low flow, low gradient aortic stenosis: the multicenter TOPAS (True or Pseudo Severe Aortic Stenosis) study. J Am Soc Echocardiogr. 2010;23:380–6.CrossRefGoogle Scholar
  34. 34.
    Clavel MA, Messika-Zeitoun D, Pibarot P, et al. The complex nature of discordant severe calcified aortic valve disease grading: new insights from combined Doppler echocardiographic and computed tomographic study. J Am Coll Cardiol. 2013;62:2329–38.CrossRefGoogle Scholar
  35. 35.
    Messika-Zeitoun D, Aubry MC, Detaint D, et al. Evaluation and clinical implications of aortic valve calcification measured by electron-beam computed tomography. Circulation. 2004;110:356–62.CrossRefGoogle Scholar
  36. 36.
    Cueff C, Serfaty JM, Cimadevilla C, et al. Measurement of aortic valve calcification using multislice computed tomography: correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction. Heart. 2011;97:721–6.CrossRefGoogle Scholar
  37. 37.
    Aggarwal SR, Clavel MA, Messika-Zeitoun D, et al. Sex differences in aortic valve calcification measured by multidetector computed tomography in aortic stenosis. Circ Cardiovasc Imaging. 2013;6:40–7.CrossRefGoogle Scholar
  38. 38.
    Clavel MA, Pibarot P, Messika-Zeitoun D, et al. Impact of aortic valve calcification, as measured by MDCT, on survival in patients with aortic stenosis: results of an international registry study. J Am Coll Cardiol. 2014;64:1202–13.CrossRefGoogle Scholar
  39. 39.
    Dweck MR, Joshi S, Murigu T, et al. Midwall fibrosis is an independent predictor of mortality in patients with aortic stenosis. J Am Coll Cardiol. 2011;58:1271–9.CrossRefGoogle Scholar
  40. 40.
    Barone-Rochette G, Pierard S, De Meester dR, et al. Prognostic significance of LGE by CMR in aortic stenosis patients undergoing valve replacement. J Am Coll Cardiol. 2014;64:144–54.CrossRefGoogle Scholar
  41. 41.
    Dweck MR, Jones C, Joshi NV, et al. Assessment of valvular calcification and inflammation by positron emission tomography in patients with aortic stenosis. Circulation. 2012;125:76–86.CrossRefGoogle Scholar
  42. 42.
    Dweck MR, Jenkins WS, Vesey AT, et al. 18F-sodium fluoride uptake is a marker of active calcification and disease progression in patients with aortic stenosis. Circ Cardiovasc Imaging. 2014;7:371–8.CrossRefGoogle Scholar
  43. 43.
    Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation. 2005;111:3290–5.CrossRefGoogle Scholar
  44. 44.
    Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation. 1997;95:2262–70.CrossRefGoogle Scholar
  45. 45.
    Rosenhek R, Zilberszac R, Schemper M, et al. Natural history of very severe aortic stenosis. Circulation. 2010;121:151–6.CrossRefGoogle Scholar
  46. 46.
    Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med. 2000;343:611–7.CrossRefGoogle Scholar
  47. 47.
    Bruch C, Stypmann J, Grude M, et al. Tissue Doppler imaging in patients with moderate to severe aortic valve stenosis: clinical usefulness and diagnostic accuracy. Am Heart J. 2004;148:696–702.CrossRefGoogle Scholar
  48. 48.
    Das P, Rimington H, Chambers J. Exercise testing to stratify risk in aortic stenosis. Eur Heart J. 2005;26:1309–13.CrossRefGoogle Scholar
  49. 49.
    Alborino D, Hoffmann JL, Fournet PC, Bloch A. Value of exercise testing to evaluate the indication for surgery in asymptomatic patients with valvular aortic stenosis. J Heart Valve Dis. 2002;11:204–9.PubMedGoogle Scholar
  50. 50.
    Lancellotti P, Lebois F, Simon M, et al. Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation. 2005;112:I377–82.PubMedGoogle Scholar
  51. 51.
    Marechaux S, Hachicha Z, Bellouin A, et al. Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. Eur Heart J. 2010;31:1390–7.CrossRefGoogle Scholar
  52. 52.
    Lancellotti P, Magne J, Donal E, et al. Determinants and prognostic significance of exercise pulmonary hypertension in asymptomatic severe aortic stenosis. Circulation. 2012;126:851–9.CrossRefGoogle Scholar
  53. 53.
    Donal E, Thebault C, O’Connor K, et al. Impact of aortic stenosis on longitudinal myocardial deformation during exercise. Eur J Echocardiogr. 2011;12:235–41.CrossRefGoogle Scholar
  54. 54.
    Lancellotti P, Moonen M, Garweg C, Pierard LA. Image. Afterload mismatch revealed by an exercise biphasic response in aortic stenosis. Arch Cardiovasc Dis. 2009;102:593–4.CrossRefGoogle Scholar
  55. 55.
    Marechaux S, Ennezat PV, LeJemtel TH, et al. Left ventricular response to exercise in aortic stenosis: an exercise echocardiographic study. Echocardiography. 2007;24:955–9.CrossRefGoogle Scholar
  56. 56.
    Lancellotti P, Donal E, Magne J, et al. Impact of global left ventricular afterload on left ventricular function in asymptomatic severe aortic stenosis: a two-dimensional speckle-tracking study. Eur J Echocardiogr. 2010;11:537–43.CrossRefGoogle Scholar
  57. 57.
    Lancellotti P, Moonen M, Magne J, et al. Prognostic effect of long-axis left ventricular dysfunction and B-type natriuretic peptide levels in asymptomatic aortic stenosis. Am J Cardiol. 2010;105:383–8.CrossRefGoogle Scholar
  58. 58.
    Lafitte S, Perlant M, Reant P, et al. Impact of impaired myocardial deformations on exercise tolerance and prognosis in patients with asymptomatic aortic stenosis. Eur J Echocardiogr. 2009;10:414–9.CrossRefGoogle Scholar
  59. 59.
    Van Pelt NC, Stewart RA, Legget ME, et al. Longitudinal left ventricular contractile dysfunction after exercise in aortic stenosis. Heart. 2007;93:732–8.CrossRefGoogle Scholar
  60. 60.
    Flett AS, Hayward MP, Ashworth MT, et al. Equilibrium contrast cardiovascular magnetic resonance for the measurement of diffuse myocardial fibrosis: preliminary validation in humans. Circulation. 2010;122:138–44.CrossRefGoogle Scholar
  61. 61.
    Flett AS, Sado DM, Quarta G, et al. Diffuse myocardial fibrosis in severe aortic stenosis: an equilibrium contrast cardiovascular magnetic resonance study. Eur Heart J Cardiovasc Imaging. 2012;13:819–26.CrossRefGoogle Scholar
  62. 62.
    Le Ven F, Tizon-Marcos H, Fuchs C, et al. Valve tissue characterization by magnetic resonance imaging in calcific aortic valve disease. Can J Cardiol. 2014;30:1676–83.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of CardiologyUniversity of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart TilmanLiègeBelgium
  2. 2.Department of CardiologyUniversity of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart TilmanLiègeBelgium
  3. 3.GVM Care and Research, E.S. Health Science FoundationLugoItaly

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