Discordant low-gradient aortic stenosis: a phenotype-first, likelihood-tiered multimodality imaging framework
- 1Department of Ultrasound, Zigong Fourth People’s Hospital
- 2Department of Radiology, Zigong First People’s Hospital
Abstract
Discordant low-gradient aortic stenosis (AS), commonly defined by the aortic valve area (AVA) ≤1.0 cm ² with mean gradient <40 mmHg and peak velocity <4.0 m/s, is reported in up to 40% of patients evaluated for AS in selected cohorts. Current guidelines and consensus documents outline echocardiographic quality control, haemodynamic phenotype assignment, dobutamine stress echocardiography (DSE), CT aortic valve calcium scoring (CT-AVC), and integrated assessment, yet uncertainty persists when haemodynamic, structural, symptomatic, and myocardial findings diverge. This narrative review proposes a phenotype-first, likelihood-tiered multimodality framework that adds four operational elements to current guidance: routine documentation of transvalvular flow rate, phenotype-specific interpretation of DSE and CT-AVC, separation of valve severity adjudication from myocardial risk refinement, and structured reporting of residual uncertainty. DSE with projected AVA is favoured for flow-dependent severity assessment in classical low-flow low-gradient AS, whereas CT-AVC likelihood categories are emphasised in preserved-ejection-fraction low-gradient phenotypes and after inconclusive DSE. Cardiovascular magnetic resonance, global longitudinal strain, extracellular volume fraction, and cardiac damage staging are used as prognostic and counselling adjuncts, not stand-alone triggers for valve intervention. Indeterminate cases are reported as unresolved discordance with the basis of uncertainty stated explicitly. The approach is intended to improve Heart Team communication and requires prospective validation before use as a treatment algorithm.
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BibTeX
@article{li2026discordant,
title = {{Discordant low-gradient aortic stenosis: a phenotype-first, likelihood-tiered multimodality imaging framework}},
author = {Yuan Li and Xue An and Yujian Liu},
journal = {Frontiers in Cardiovascular Medicine},
year = {2026},
month = nov,
doi = {10.3389/fcvm.2026.1901893},
url = {https://www.frontiersin.org/articles/10.3389/fcvm.2026.1901893/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Discordant low-gradient aortic stenosis: a phenotype-first, likelihood-tiered multimodality imaging framework
AU - Yuan Li
AU - Xue An
AU - Yujian Liu
PY - 2026
DA - 2026/11/09
JO - Frontiers in Cardiovascular Medicine
DO - 10.3389/fcvm.2026.1901893
UR - https://www.frontiersin.org/articles/10.3389/fcvm.2026.1901893/full
AB - Discordant low-gradient aortic stenosis (AS), commonly defined by the aortic valve area (AVA) ≤1.0 cm ² with mean gradient <40 mmHg and peak velocity <4.0 m/s, is reported in up to 40% of patients evaluated for AS in selected cohorts. Current guidelines and consensus documents outline echocardiographic quality control, haemodynamic phenotype assignment, dobutamine stress echocardiography (DSE), CT aortic valve calcium scoring (CT-AVC), and integrated assessment, yet uncertainty persists when haemodynamic, structural, symptomatic, and myocardial findings diverge. This narrative review proposes a phenotype-first, likelihood-tiered multimodality framework that adds four operational elements to current guidance: routine documentation of transvalvular flow rate, phenotype-specific interpretation of DSE and CT-AVC, separation of valve severity adjudication from myocardial risk refinement, and structured reporting of residual uncertainty. DSE with projected AVA is favoured for flow-dependent severity assessment in classical low-flow low-gradient AS, whereas CT-AVC likelihood categories are emphasised in preserved-ejection-fraction low-gradient phenotypes and after inconclusive DSE. Cardiovascular magnetic resonance, global longitudinal strain, extracellular volume fraction, and cardiac damage staging are used as prognostic and counselling adjuncts, not stand-alone triggers for valve intervention. Indeterminate cases are reported as unresolved discordance with the basis of uncertainty stated explicitly. The approach is intended to improve Heart Team communication and requires prospective validation before use as a treatment algorithm.
SN - 2297-055X
ER -