Aug 2026· Cardiology in Review· 0 citations· 35 references
Medicine
TL;DR
Integration of echocardiography, computed tomography, CMR, and emerging positron emission tomography and artificial intelligence-based approaches can help address diagnostic uncertainty in aortic stenosis.
Abstract
Aortic stenosis (AS) is the most common degenerative valvular disease in elderly patients and is linked to high morbidity and mortality. Accurate diagnosis and risk stratification are critical for effective management. Transthoracic echocardiography is the standard diagnostic tool, but its reliance on flow-dependent parameters can lead to inconsistent grading, especially in low-flow, low-gradient, or normal-flow, low-gradient AS. Advanced echocardiographic methods, such as 3D imaging, stress echocardiography, and Doppler indices, such as the mean gradient-to-effective orifice area ratio, improve the evaluation of AS severity and assist in clinical decision-making. Computed tomography provides a flow-independent evaluation of AS. It uses noncontrast calcium scoring with sex-specific thresholds, along with contrast-enhanced angiography, for detailed anatomical assessment. These modalities are essential for procedural planning, particularly for transcatheter aortic valve replacement. Cardiac magnetic resonance (CMR) provides additional prognostic information. It quantifies myocardial remodeling and fibrosis, which are associated with outcomes and recovery potential. Emerging technologies are expanding diagnostic capabilities in AS. Examples include 18F-sodium fluoride positron emission tomography for detecting microcalcification, artificial intelligence-based ECG and echocardiography for early diagnosis, and 4D flow CMR. Integration of echocardiography, computed tomography, CMR, and emerging positron emission tomography and artificial intelligence-based approaches can help address diagnostic uncertainty. This integration helps refine AS subtype classification and inform individualized intervention strategies.
Moderate aortic stenosis (AS) has traditionally been considered a transitional and relatively benign stage of valvular disease. Yet, contemporary evidence shows that it is associated with substantial morbidity and mortality even before progression to severe AS. This paper synthesizes current evidence on the limitations of standard echocardiography, highlights the role of advanced imaging and artificial intelligence, and outlines evolving strategies for risk stratification and clinical management. Multimodality imaging provides a more accurate assessment of disease severity beyond conventional echocardiographic parameters: computed tomography aortic valve calcium scoring, cardiac magnetic resonance, and 18 F-sodium fluoride positron emission tomography reveal early myocardial injury and identify rapid progressors. AI further enhances reproducibility and supports the development of emerging prognostic models. A staging approach that integrates ventricular, atrial, and right-sided involvement correlates more closely with clinical outcomes than valve metrics alone, enabling a more comprehensive characterization of disease burden. Although guideline-directed surveillance remains the standard strategy for most patients, selected high-risk individuals, particularly those with adverse remodeling, elevated biomarkers, or recurrent heart failure admissions, may benefit from earlier intervention. While waiting for the results of ongoing randomized trials cardiologist should implement all the imaging multimodality tools available in order to individuate patients in which an earlier treatment of moderate AS will more probably improve long-term outcomes.
G. Santangelo, Alessandro Maloberti, C. Tognola et al.· Cardiovascular Ultrasound· 0 citations
Cardiovascular imaging plays a central role in the diagnosis, risk stratification, and longitudinal management of cardiovascular disease during pregnancy. Physiological adaptations-including increased blood volume, cardiac output, and chamber remodeling-pose important challenges for image acquisition and interpretation, necessitating a nuanced understanding of normal versus pathological findings. This review provides a practical, cardiology-focused framework for the use of imaging in pregnant patients with suspected or established cardiovascular disease. We emphasize key aspects relevant to cardiac imagers, including appropriate modality selection, pregnancy-adapted imaging protocols, and interpretation of findings in the context of dynamic physiological changes. Transthoracic echocardiography remains the first-line modality, while cardiovascular magnetic resonance offers complementary, radiation-free evaluation in selected cases. Imaging techniques involving ionizing radiation, such as computed tomography and invasive angiography, should be reserved for acute or high-risk scenarios and carefully optimized to minimize fetal exposure. We further discuss common diagnostic pitfalls, limitations of each modality, and areas of uncertainty, including the use of contrast agents and thresholds for advanced imaging. The importance of integrating imaging findings into multidisciplinary decision-making within Pregnancy Heart Teams is highlighted. By providing a structured, clinically oriented approach, this review aims to support cardiac imagers in delivering safe, accurate, and evidence-informed care to this complex patient population.
A. V. Van Berendoncks, J. R. Rodríguez Palomares, J. D. De Backer· Circulation Cardiovascular I...· 0 citations
Mitral regurgitation (MR) is the most prevalent valvular heart disease in developed countries, affecting approximately 1 in 50 individuals in the general population and about 1 in 10 individuals older than 75 years. Despite its frequency, MR remains a complex clinical challenge due to its heterogeneous etiology, variable natural history, and evolving therapeutic landscape. The 2025 ESC/EACTS guidelines have introduced a paradigm shift, transitioning from a purely morphological classification to a mechanism-based framework that distinguishes primary, ventricular secondary, and atrial secondary MR. This review provides a comprehensive overview of contemporary MR management. We discuss the updated classification system and the associated implications for risk stratification, emphasizing how the underlying mechanism of MR influences prognosis and guides treatment selection. The diagnostics section addresses multimodality imaging strategies, detailing the complementary roles of echocardiography, cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT) in assessing severity, characterizing anatomy, and planning interventions. The management section addresses optimization of medical therapy, surgical techniques (repair versus replacement, including conventional and minimally invasive approaches), and transcatheter interventions, with particular focus on mitral transcatheter edge-to-edge repair (M-TEER) and emerging transcatheter mitral valve replacement technologies. We propose an integrated, stepwise management algorithm that incorporates early risk markers, including natriuretic peptides, to guide the timing of intervention before irreversible myocardial damage occurs. The critical role of multidisciplinary heart valve teams (HVTs) in individualizing treatment decisions is highlighted throughout. Early recognition of MR and timely intervention are paramount to prevent progression to irreversible left ventricular dysfunction and heart failure. The mechanism-based classification enables more precise patient phenotyping and treatment tailoring. Transcatheter therapies have expanded therapeutic options for high-risk surgical patients, although careful patient selection remains essential. Natriuretic peptides have emerged as valuable biomarkers for identifying candidates who may benefit from earlier intervention. Contemporary MR management requires the integration of advanced imaging, mechanism-based classification, and collaborative decision-making within HVTs. As therapeutic options continue to expand, optimal outcomes depend on matching the right intervention to the right patient at the right time.
C. Gaspardone, Paolo Costa, G. Barone et al.· Reviews in cardiovascular me...· 0 citations
Carotid web (CaW) is a nonatherosclerotic vascular anomaly and an underdiagnosed cause of embolic ischemic stroke, particularly in young patients without traditional vascular risk factors. Its intraluminal position and morphology produce local hemodynamic disturbances that promote thrombus formation and account for the high rate of recurrent distal embolism reported with medical therapy alone. Accurate diagnosis relies on careful evaluation with computed tomography angiography and multiplanar reconstructions, as CaW may be overlooked on conventional imaging. Current evidence indicates that, in symptomatic patients, antithrombotic therapy alone is insufficient to prevent early recurrence, whereas carotid revascularization with endarterectomy or stenting provides excellent safety and efficacy. In contrast, optimal management of asymptomatic CaW remains uncertain and is generally based on clinical and imaging surveillance. This review summarizes the diagnostic features, natural history, and treatment strategies of CaW and presents a practical algorithm to support clinical decision-making in neurovascular practice.
Leonardo D. Cura-Rodríguez, G. Lanzino, L. Rangel-Castilla· Contemporary Neurosurgery· 0 citations
CT-derived AVA demonstrates strong agreement with TTE and provides complementary information for severity assessment and risk stratification in patients with aortic stenosis, particularly in cases with discordant or borderline findings.
Shehroz Sultan, Neeraj Joshi, A. H. Awan et al.· Journal of Community Hospita...· 0 citations
Abstract Over the last decade, transcatheter structural heart interventions (TSHIs) have revolutionized the management of patients with structural heart disease (SHD), particularly those deemed high-risk or inoperable for conventional surgery. This rapid evolution has been propelled by innovations in both device technology and cardiovascular imaging, with echocardiography emerging as a cornerstone for procedural planning, real-time guidance and post-procedural assessment. This review outlines the expanding role of echocardiography across the spectrum of TSHIs, highlighting the importance of multimodality imaging, including three-dimensional transoesophageal echocardiography (3D TEE), intracardiac echocardiography (ICE) and fusion imaging techniques, for comprehensive structural evaluation and intraprocedural navigation. As the field continues to evolve, the demand for imaging specialists with procedural expertise is growing. Challenges remain in optimizing workflow, minimizing radiation exposure and enhancing image-guided precision. This review aims to outline the development of interventional imaging and promote best practices for procedural success and patient safety.
N. Ktenopoulos, K. Vlasopoulou, P. Vlachakis et al.· European heart journal. Imag...· 0 citations
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