Revealing the Hidden Severity: A Case Report on Managing Complex Aortic Stenosis With TAVI.

Aortic stenosis (AS) is a progressive condition prevalent in older adults, with severity determined through clinical evaluation and imaging. However, diagnostic dilemmas arise when imaging results conflict with clinical symptoms. This report examines an 84-year-old male with chronic kidney disease, prior abdominal aortic aneurysm repair and other comorbidities, presenting with decompensated heart failure. Initial echocardiography findings suggested moderate AS, insufficient to qualify for transcatheter aortic valve implantation (TAVI) under national guidelines, despite clinical evidence of worsening heart failure. A multimodal diagnostic approach, incorporating Agatston scoring, dobutamine stress echocardiography (DSE), and invasive haemodynamics, was undertaken to resolve this discordance. DSE demonstrated persistent discordance between Doppler- and Simpson-derived flow estimates, whereas CT calcium scoring and left heart catheterisation ultimately confirmed severe AS, with an aortic valve area of 0.75 cm2. The patient underwent preoperative optimisation, including multidisciplinary team (MDT) input and targeted interventions to manage comorbidities and optimise haemodynamics. TAVI was performed successfully, resulting in significant improvements in symptoms, exercise tolerance and renal function. This case highlights the necessity of a multimodal diagnostic strategy when initial investigations do not align with clinical presentation, emphasising MDT collaboration and preoperative optimisation. It demonstrates how multimodality imaging can prevent underestimation of AS severity and support timely intervention in clinically complex patients.