Sara Bombace

Aortic stenosis (AS) is increasingly recognized as a complex myocardial disease rather than an isolated valvular disorder. Emerging translational and clinical evidence suggests that diastolic dysfunction in AS is not merely an epiphenomenon of aging or comorbidity burden but develops early and may represent a central mechanistic link between valvular obstruction and heart failure. Chronic left ventricular pressure overload increases wall stress and myocardial oxygen demand, triggering a cascade of structural, metabolic, and microvascular alterations that culminate in left ventricular hypertrophy, interstitial fibrosis, impaired relaxation, and reduced ventricular compliance. The severity of diastolic dysfunction before aortic valve replacement significantly influences clinical outcomes. Persistent myocardial fibrosis and impaired diastolic reserve may remain despite successful valve intervention, helping explain why a substantial proportion of patients continue to experience heart failure symptoms after valve replacement. Despite its clinical relevance, diastolic dysfunction remains insufficiently integrated into current guideline-directed decision-making, raising the question of whether it should assume a more central role in determining the optimal timing of aortic valve replacement. Beyond correction of valvular obstruction alone, diastolic dysfunction may therefore represent both a marker of advanced myocardial remodeling and a potential therapeutic target in patients with AS.

Over the last ten years, transcatheter tricuspid valve interventions (TTVIs) have emerged as effective options for symptomatic patients with moderate-to-severe tricuspid regurgitation (TR) who are at prohibitive surgical risk. Successful application of these therapies depends on a patient-tailored, multimodal imaging workflow. Transthoracic and transesophageal echocardiography remain the first-line diagnostic tools, rapidly stratifying TR severity, mechanism, and right ventricular function, and identifying cases requiring further evaluation. Cardiac computed tomography (CT) then provides anatomical detail—quantifying tricuspid annular dimension, leaflet tethering, coronary artery course, and venous access anatomy—to refine candidacy and simulate optimal device sizing and implantation angles. In patients with suboptimal echocardiographic windows or equivocal functional data, cardiovascular magnetic resonance (CMR) offers gold-standard quantification of RV volumes, ejection fraction, regurgitant volume, and tissue characterization to detect fibrosis. Integration of echo-derived parameters, CT anatomical notes, and CMR functional assessment enables the heart team to better select patients, plan procedures, and determine the optimal timing, thereby maximizing procedural success and minimizing complications. This review describes the current strengths, limitations, and future directions of multimodality imaging in comprehensive evaluations of TTVI candidates.