Evolution of Cardiac Damage Across Clinically Defined Stages of Aortic Stenosis in Patients Undergoing TAVR: A Single-Center Retrospective Cohort Study

<b>Background:</b> Echocardiography is essential for diagnosing and guiding therapy in aortic stenosis (AS). Cardiac damage staging systems may better characterize myocardial and extracardiac involvement. We aim to evaluate the presence and progression of cardiac damage across the clinical course of AS. <b>Methods:</b> A single-center retrospective cohort study was conducted, which included consecutive patients who ultimately underwent TAVR and had retrievable serial echocardiograms at moderate AS, first severe AS, and pre-TAVR symptomatic severe AS (2017-2021). A total of 179 patients were evaluated (mean age 82.7 [5.9] years at moderate AS; 46% male, <i>p</i> = 0.27). Cardiac damage was classified according to two established staging systems. <b>Results:</b> The median time from moderate to severe AS was 32 months (IQR 18-48). Most echocardiographic parameters deteriorated primarily at symptom onset, whereas moderate AS and first severe (asymptomatic) AS showed broadly similar profiles. However, left ventricular global longitudinal strain (LV GLS) was already impaired at the first severe stage, and right ventricular-arterial coupling (RVAc, TAPSE/sPAP) progressively worsened as AS advanced to the severe stage, independently of symptom status (LV GLS -18.1%, n = 163; -17.1%, n = 143; and -14.9%, n = 143; RVAc 1.0, n = 131; 0.8, n = 130; and 0.7, n = 130), respectively; overall <i>p</i> < 0.05. Both staging systems demonstrated increasing cardiac damage with AS progression. <b>Conclusions:</b> Cardiac damage may occur early in AS. The marked deterioration at symptom onset underscores the importance of systematic myocardial assessment and supports prospective studies to evaluate whether integrating LV GLS and RVAc as sensitive early markers of disease progression improves risk stratification.