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velocity integral (TVI) to that of the aortic valve jet—does not require calculation of LVOT area and may assist evaluation when other parameters are equivocal (a value <0.25 suggests that severe aortic stenosis is highly likely).156 Assessment of global longitudinal strain provides additional information concerning LV function and a threshold of 15% may help to identify patients with severe asymptomatic aortic stenosis who are at higher risk of clinical deterioration or premature mortality.26,168 TOE allows evaluation of concomitant mitral valve disease and may be of value for periprocedural imaging during TAVI and SAVR.169 Natriuretic peptides predict symptom-free survival and outcome in normal and low-flow severe aortic stenosis.170,171 They can be used to arbitrate the source of symptoms in patients with multiple potential causes and identify those with high-risk asymptomatic aortic stenosis who may benefit from early intervention (section 5.2.2, Table 6 and Figure 3). Exercise testing may unmask symptoms and is recommended for risk stratification of asymptomatic patients with severe aortic stenosis.172 Exercise echocardiography provides additional prognostic information by assessing the increase in mean pressure gradient and change in LV function.173 CCT provides information concerning the anatomy of the aortic root and ascending aorta, and the extent and distribution of valve and vascular calcification, and feasibility of vascular access.174 Quantification of valve calcification predicts disease progression and clinical events164 and may be useful when combined with geometric assessment of valve area in assessing the severity of aortic stenosis in patients with low valve gradient.35,36,163,164 Myocardial fibrosis is a major driver of LV decompensation in aortic stenosis (regardless of the presence or absence of CAD), which can be detected and quantified using CMR. Amyloidosis is also frequently associated with aortic stenosis in elderly patients (incidence 915%).175 When cardiac amyloidosis is clinically suspected, based on symptoms (neuropathy and hematologic data), diphosphonate scintigraphy and/or CMR should be considered. Both entities persist following valve intervention and are associated with poor long-term prognosis.176179 Coronary angiography is essential prior to TAVI and SAVR to determine the potential need for concomitant revascularization (see section 3.2.4.1 and section 5.5). Retrograde LV catheterization is not recommended unless there are symptoms and signs of severe aortic stenosis and non-invasive investigations are inconclusive.

5.1.3 TAVI diagnostic workup Prior to TAVI, CCT is the preferred imaging tool to assess: (i) aortic valve anatomy, (ii) annular size and shape, (iii) extent and distribution of valve and vascular calcification, (iv) risk of coronary ostial obstruction, (v) aortic root dimensions, (vi) optimal fluoroscopic projections for valve deployment, and (vii) feasibility of vascular access (femoral, subclavian, axillary, carotid, transcaval or transapical). Adverse anatomical findings may suggest that SAVR is a better treatment option (Table 6). TOE is more operator-dependent but may be considered when CCT is difficult to interpret or relatively contraindicated (e.g. chronic renal failure). Table 6 Clinical, anatomical and procedural factors that influence the choice of treatment modality for an individual patient

Favours Favours TAVI SAVR

Clinical characteristics Lower surgical risk 2 1 Higher surgical risk 1 2 Younger agea 2 1 Older agea 1 2 Previous cardiac surgery (particularly intact coronary artery bypass grafts at risk of injury during repeat sternotomy) 1 2 Severe frailtyb 1 2 Active or suspected endocarditis 2 1 Anatomical and procedural factors TAVI feasible via transfemoral approach 1 2 Transfemoral access challenging or impossible and SAVR feasible Transfemoral access challenging or impossible and SAVR inadvisable 2 1c 1

2 Sequelae of chest radiation 1 2

Porcelain aorta 1 2 High likelihood of severe patientprosthesis mismatch (AVA <0.65 cm2/m2 BSA) 1 2 Severe chest deformation or scoliosis 1 2 Aortic annular dimensions unsuitable for available TAVI devices 2 1 Bicuspid aortic valve 2 1 Valve morphology unfavourable for TAVI (e.g. high risk of coronary obstruction due to low coronary ostia or heavy leaflet/LVOT calcification) 2 1 Thrombus in aorta or LV 2 1 Concomitant cardiac conditions requiring intervention Significant multi-vessel CAD requiring surgical revascularizationd 2 1 Severe primary mitral valve disease 2 1 Severe tricuspid valve disease 2 1 Significant dilatation/aneurysm of the aortic root and/or ascending aorta 2 1 Septal hypertrophy requiring myectomy 2 1 AVA = aortic valve area, BSA = body surface area, CAD = coronary artery disease; ESC = European Society of Cardiology; LV = left ventricle/left ventricular; LVOT = left ventricular outflow tract; SAVR = surgical aortic valve replacement; TAVI = transcatheter aortic valve implantation. Integration of these factors provides guidance for the Heart Team decision (indications for intervention are provided in the table of recommendations on indications for intervention in symptomatic and asymptomatic aortic stenosis and recommended mode of intervention). aLife expectancy is highly dependent on absolute age and frailty, differs between men and women, and may be a better guide than age alone. There is wide variation across Europe and elsewhere in the world (http://ghdx.healthdata.org/ record/ihme-data/gbd-2017-life-tables-1950-2017). bSevere frailty = >2 factors according to Katz index59 (see section 3.3 for further discussion). cVia non-transfemoral approach. dAccording to the 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. ESC/EACTS 2021

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