Shaping the Optimal Timing for Treatment of Isolated Asymptomatic Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction: The Role of Non-Invasive Diagnostics Focused on Strain Echocardiography and Future Perspectives

The optimal timing for treatment of patients with isolated asymptomatic severe aortic stenosis and preserved left ventricular ejection fraction is still controversial and research is ongoing. Once a diagnosis has been performed and other cardiac comorbidities (e.g., concomitant significant valvulopathies or infiltrative cardiomyopathies) have reasonably been excluded, a hot topic is adequate myocardial characterization, which aims to prevent both myocardial dysfunction and subsequent adverse myocardial remodeling, and can potentially compromise the post-treatment outcomes. Another crucial subject of debate is the assessment of the real "preserved" left ventricular ejection fraction cut-off value in the presence of isolated asymptomatic severe aortic stenosis, in order to optimize the timing of aortic valve replacement as well. The aim of the present critical narrative review is highlighting the current role of non-invasive diagnostics in such a setting, focusing on strain echocardiography, and citing the main complementary cardiac imaging techniques, as well as suggesting potential implementation strategies in routine clinical practice in view of future developments.