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EACVI Survey - Multimodality Imaging in the Evaluation and Management of Aortic Stenosis: Alignment with ESC/EACTS 2025 Guidelines

Aortic valve stenosis (AS) is a progressive disease in which multimodality imaging plays a central role in diagnosis, risk stratification, and treatment decision-making. While echocardiography remains the first-line imaging technique, transoesophageal echocardiography (TEE), computed tomography (CT), stress echocardiography, and cardiac MRI (CMR) provide essential complementary information—particularly in complex, low-flow low-gradient (LFLG), or discordant cases.

Despite established ESC/EACVI recommendations, there is substantial variability in the application, interpretation, and integration of these modalities across European centres. This survey aims to systematically assess real-world practice patterns, knowledge gaps, technical approaches, and challenges faced by clinicians using multimodality imaging in AS.

Thank you for participating in this EACVI survey.
May we remind you of the codes of conduct related to market research among healthcare professionals:
• The survey is anonymous
• You have the right to end your participation in this survey at any time
• We comply with the European General Data Protection Regulation (GDPR) 2016/679.
Any personal data processed in connection with this survey will be treated confidentially and only used for the purposes of market research. Material and data collected from you will be analysed overall, used internally by the ESC and kept for a maximum of 24 months for analysis and quality control purposes. We take all reasonable care to prevent any unauthorised access to your personal data. We respect your privacy and your right to access, modify, or suppress your personal data. At any time, you can ask to know what personal data is being held.
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1.May we please ask you to confirm you have read the clauses above and accept participation in this survey?
Section 1 – Respondent Profile
2.In which Country do you practice?
3.What is your primary professional role?
4.Years of clinical experience
5.In which type of institution do you primarily work?
6.Please estimate the annual number of patients with severe AS evaluated in your centre
Section 2- Echocardiography as First-Line Imaging
7.To what extent do you agree with the following statements?
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Transthoracic echocardiography provides sufficient information to classify AS severity in the majority of patients.
Measurement errors (e.g. LVOT diameter, Doppler alignment) frequently contribute to discordant grading in AS.
Stroke volume index is routinely assessed as part of AS evaluation in my institution.
The dimensionless index is routinely used when AVA and gradient are discordant.
Section 3- Management of Discordant findings in Aortic Stenosis
8.How frequently are the following approaches used in the evaluation and management of patients with discordant AS findings in your clinical practice?
Never
Rarely
Sometimes
Often
Always
Additional imaging evaluation is performed in cases of discordant AS severity (AVA <1.0 cm² and mean gradient <40 mmHg).
The current AVA threshold (<1.0 cm²) reflects AS severity in all patients
Cardiac CT aortic valve calcium scoring (AVCS) is used to confirm severe AS in patients with discordant echocardiographic findings, including those with paradoxical low-flow, low-gradient AS.
BSA-indexed aortic valve calcium scoring (AVC/BSA) is used when interpreting CT calcium burden in patients with suspected severe AS.
Section 4- Role of Multimodality Imaging
9.To what extent do you agree with the following statements?
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Cardiac CT is underutilised in the diagnostic work-up of AS in clinical practice.
Myocardial fibrosis detected by CMR should influence the timing of intervention in severe AS.
CMR should be systematically performed to rule out concomitant amyloidosis in patients with AS and not univocal echocardiographic findings.
Low-dose dobutamine stress echocardiography is used in the evaluation of patients with paradoxical low-flow, low-gradient AS.
Section 5- Management of patients with Asymptomatic Severe AS
10.How frequently are the following approaches used in the management of patients with asymptomatic severe AS in your clinical practice?
Never
Rarely
Sometimes
Often
Always
Exercise stress echocardiography is used to detect symptoms in the diagnostic pathway of apparently asymptomatic patients with severe AS.
Biomarkers (BNP/NT-proBNP) are evaluated for risk-stratification in patients with asymptomatic severe AS.
Multimodality imaging is used to inform decision-making regarding early intervention in asymptomatic severe AS.
11.Which findings would most strongly trigger referral for intervention in an asymptomatic severe AS patient in your institution? (Select maximum 3 options)(Required.)
Section 6- Imaging and Procedure Selection
12.To what extent do you agree with the following statements?
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Multimodality imaging significantly improves Heart Team decision making regarding the correct timing of intervention in patients with AS.
CT imaging is essential for treatment strategy (selecting candidates for TAVI vs SAVR) and procedural planning (including device selection).
Section 7- Barriers to Multimodality Imaging
13.How significant are the following barriers to the use of multimodality imaging in your clinical practice?
Not a barrier
Minor
Moderate
Major
Critical
Limited access to cardiac CT
Limited availability of CMR
Reimbursement and healthcare system constraints
Lack of integration between imaging specialists and Heart Teams
Section 8- Future Directions
14.To what extent do you agree with the following statements?
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Multimodality imaging has the potential to play a greater role in determining the timing of intervention in AS but should be demonstrated in dedicated trial.
Artificial intelligence will improve the diagnostic evaluation of AS.
Standardised multimodality imaging algorithms should be implemented across Europe.
Section 9- Final Question
15.What do you consider the most important unmet need in the imaging evaluation of aortic stenosis?