Precision pathways in patients with aortic stenosis awaiting TAVI: act beyond symptoms

Valve disease Course resource

09 April 2026

The management of patients with aortic stenosis awaiting TAVI has shifted from isolated valve assessment to a comprehensive myocardial disease evaluation. This case-based iHF Course session led by Jozef Bartunek and Emanuele Barbato explores how precision diagnostic pathways and targeted screening optimise outcomes for complex heart failure patients.

Precision work-up and staging

Relying solely on symptoms often leads to delayed intervention. While echocardiography remains the primary screening tool, this session emphasizes the critical value of invasive left and right heart catheterisation for patients with aortic stenosis awaiting TAVI:

Beyond Valve Gradients: Catheterisation provides essential data on left and right ventricular pressures, pulmonary pressures, and PCWP.
Resolving Discordance: Invasive measurements help reconcile discrepancies between echo-derived gradients and calculated valve areas, particularly in low-flow, low-gradient (LFLG) phenotypes.
Outcome Correlation: Precise hemodynamic staging directly correlates with post-procedural morbidity and mortality.

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Targeted screening for coexisting cardiomyopathies

A significant portion of patients with aortic stenosis awaiting TAVI may have coexisting conditions like cardiac amyloidosis, with a prevalence reaching up to 25% in certain cohorts. This proportion is often underestimated, even though cardiac amyloidosis has a very important effect on valves and ventricles, affecting the heart as a whole.
Key red flags such as heart failure, atrial fibrillation, carpal tunnel syndrome, back pain or hypotension, must be monitored to detect coexisting cardiac amyloidosis. Several factors impact the prognosis in patients with aortic stenosis and amyloidosis:

Degree of AS: Low-flow, low-gradient AS, advanced severity
Right Ventricular Dysfunction: RV failure, elevated pulmonary pressure
Extent of amyloid infiltration
Biomarkers: Troponin, BNP, NT-proBNP
Comorbidities: Frailty, age, atrial fibrillation, diabetes…

Dynamic Risk Stratification and Timing of Intervention

The decision for TAVI in aortic stenosis must be a dynamic process, moving beyond simple symptom onset to a multi-parametric risk assessment.

Frailty and Geriatric Assessment

Comprehensive geriatric assessment is central to estimating the utility versus futility of the procedure in patients over 85. Frailty is viewed as a dynamic state that may be improved through pre-procedural nutritional and exercise interventions.

Emerging Evidence for Early TAVI

The session also reviews emerging evidence from trials like AVATAR and Early TAVR, supporting earlier, pre-emptive intervention in asymptomatic aortic stenosis patients to prevent sudden hemodynamic decline and reduce heart failure hospitalisations.
Optimal decongestion management and valve repair must be integrated. Success requires a multidisciplinary "Heart Team" approach that combines tailored valve therapy with guideline-directed medical therapy (GDMT), including SGLT2 inhibitors.
Watch the full session replay to master these precision protocols and redefine the standards of care for your aortic stenosis patients.