Categories of Aortic Stenosis: What's New and the Clinical Implications

Aortic valve stenosis (AS) is assessed by echocardiography in clinical practice. Conventionally, the aortic valve area, peak transaortic valve velocity/gradient and the mean transvalvular gradient determine if the AS is categorized as mild, moderate or severe. Recently, the entity of paradoxical low-flow, low-gradient AS despite normal left ventricular ejection fraction (LVEF) was described and flow (as determined by stroke volume indexed to body surface area) was used to further categorize AS. The new European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) guidelines in 2025 recommended a new phenotype-based classification, which improved the prognostication of AS. There are now five phenotypes: (1) concordant high-gradient AS; (2) low-flow, low-gradient AS with reduced LVEF; (3) low-flow, low-gradient AS with preserved LVEF; (4) normal-flow, low-gradient AS with preserved LVEF; and (5) discordant high-gradient AS. These appear to have different underlying pathophysiology, and hence prognostication and therapy. In addition, categories of AS in the setting of reduced LVEF are further divided based on their responses to dobutamine or exercise stress, which may result in different therapeutic strategies. In the transaortic valvular replacement (TAVR) versus the surgical aortic valve replacement (SAVR) era, the classification of these AS groups may have differing implications on the appropriate interventions. Furthermore, there are investigations on the effect of AS on the left ventricle and other chambers and stages of AS based on the extent of cardiac damage, which may have important prognostic value post-AVR. On the other spectrum, there are new developments in imaging analysis, such as using artificial intelligence. This state-of-the-art paper will comprehensively review the important updates in AS and its clinical implications.