Aortic stenosis: past, present and future perspectives

Aortic stenosis is the most frequent valvular heart disease in developed countries and is a growing cause of morbimortality amongst the elder population. Its pathophysiology is common to atherosclerosis, characterized by chronic inflammation, lipid deposition, and progressive valve calcification. Surgical aortic valve replacement has been historically the gold-standard therapy, providing excellent outcomes in both survival and quality of life. However, the arrival of transcatheter aortic valve implantation has transformed the management of aortic stenosis, offering an effective and less invasive alternative, initially in inoperable or high-risk patients, but now also in intermediate- and even low-risk groups. Despite these advances, challenges still remain, including durability, prevention of procedure-specific complications, optimal patient selection, and long-term cost-effectiveness. Moreover, no pharmacological therapy has yet proven to modify the natural course, although ongoing research on drugs targeting lipoprotein(a), SGLT2 inhibitors, and novel biomarkers provide promising insights. The future of aortic stenosis management is moving towards a more personalized medicine using more durable prosthesis, integrating all different biomarkers using artificial intelligence-based predictive models in order to guide therapies, and continue investigating drugs that could in turn modify the natural history of this disease.