Multimodality Imaging to Explore Sex Differences in Aortic Stenosis

The aim of this article is to review sex differences in aortic stenosis (AS) assessed with multimodality imaging. Echocardiography remains the mainstay imaging technique to diagnose AS and provides important insights into the differences between men and women in relation to valve haemodynamic and left-ventricular response. However, echocardiography does not have adequate resolution to provide important insights into sex differences in the degenerative, calcific pathophysiological process of the aortic valve. CT shows that women with AS have more fibrotic changes of the aortic valve whereas men show more calcific deposits. Cardiac magnetic resonance shows that women have left ventricles that are less hypertrophic and smaller compared with those of men, while men have more replacement myocardial fibrosis. These differences may lead to different responses to aortic valve replacement because myocardial diffuse fibrosis but not replacement myocardial fibrosis may regress after the procedure. Sex differences in the pathophysiological process of AS can be assessed using multimodality imaging, assisting in decisionmaking in these patients.