Lung water and coronary flow as complementary signals in aortic valve replacement

Pulmonary congestion and coronary microvascular dysfunction are central to hemodynamic adaptation before and after transcatheter aortic valve replacement (TAVR). This perspective proposes an exploratory, physiology-anchored framework that integrates lung ultrasound (LUS) and transthoracic Doppler of the left anterior descending artery (LAD) to track these domains on the same bedside platform. A concise anterior four-site LUS sampling captures early, posture- and stress-dependent interstitial congestion, while LAD Doppler provides a non-invasive window on resting diastolic coronary flow velocity (CFV) and CFV reserve (CFVR). In severe aortic stenosis, valve unloading with TAVR typically reduces filling pressures and restores diastolic coronary flow, though CFV and CFVR responses vary with the balance between myocardial oxygen demand and improved hyperemia. Interpreting these signals alongside standard echocardiographic indices (E/e’, LAVI, SPAP, and Doppler velocity index) ensures physiological coherence and avoids misattribution. Rather than focusing on numeric thresholds, this approach emphasizes trajectories—how B-lines, CFV, and CFVR evolve from baseline to post-TAVR follow-up. Concordant improvement supports decongestion and microvascular recovery, whereas discordance prompts investigation of right-sided or extra-cardiac mechanisms. Readily implemented with existing echocardiographic equipment, the combined LUS-LAD strategy offers a scalable, hypothesis-generating tool to explore pulmonary-coronary interactions, guide decongestive and anti-ischemic therapy, and inform future feasibility and reproducibility studies in the TAVR population.