Understanding the Transvalvular Gradient in Aortic Stenosis: A Multifaceted Perspective.

Growing age-related epidemiology, together with an increasing burden of cardiac co-pathology and comorbidities, has progressively subverted the clinical paradigm of Aortic Stenosis (AS) towards a multifaceted scenario. Timely surgical or transcatheter valve replacement is paramount to reduce morbidity and mortality in AS patients provided that the obstruction is hemodynamically important and responsible for the symptoms across a variety of clinical contexts. Despite its recognized role in AS assessment severity, transvalvular gradient (TVG) reflects complex interplay among anatomical, mechanical and fluid-dynamic factors, challenging the ultimate recognition of significant aortic valve obstruction. Careful phenotyping of TVG by assessing its underlying variables may enhance diagnostic work-up, risk stratification and management of AS. Emerging imaging modalities, such as three-dimensional echocardiography, automatic flow and myocardial function assessment, and advanced fluid dynamics analysis are promising for refining multifaceted TVG phenotypes. A deeper understanding of the substrate underlying TVG may add new insight into the trajectory of valve obstruction and its interaction with left ventricular function, thereby supporting the tailoring of TVG-guided clinical strategies of the evolving scenario of AS.