Treatment Decision in Aortic Stenosis—Look at the Valve but Do Not Forget the Ventricle

In patients with aortic stenosis, current guidelines recommend valve replacement therapy in case of severe valve narrowing in combination with symptoms and/or left ventricular dysfunction (ejection fraction < 50%). It is increasingly recognized that left ventricular ejection fraction offers a crude interpretation of a complex disease entity that is in need of refinement to optimize the timing of valve replacement therapy and patient outcome. In this state-of-the-art review article, we discuss the pathophysiological transition from left ventricular hypertrophy to other types of cardiac remodeling and myocardial fibrosis in response to progressive narrowing of the aortic valve, and how new imaging developments and biomarkers may help identify patients with a dismal outcome at earlier stages of disease. Also, the digital transformation of health care and novel analytical methods such as artificial intelligence that can help improve treatment decision is evaluated. This is in combination with the increased use of minimally invasive treatment modalities that may fulfill the goal of offering valve replacement in patients with aortic stenosis at earlier stages of disease and prior to the onset of symptoms but nevertheless at risk of left ventricular deterioration.