Background and Objectives: Aortic stenosis (AS) is a frequent valvular disease characterized by the obstruction of left ventricular outflow. The resulting hemodynamic and structural changes create an arrhythmogenic substrate, with sudden cardiac death (SCD) often caused by ventricular arrhythmias (VAs) being a feared complication. This review examines the relationship between severe AS and VA, detailing the epidemiology, pathophysiological mechanisms, risk factors, and management approaches prior to aortic valve replacement (AVR). Materials and Methods: We conducted a comprehensive narrative review of the historical and contemporary literature investigating ventricular arrhythmias in severe aortic stenosis. Literature searches were performed in PubMed, MEDLINE, and Scopus databases using keywords, including "aortic stenosis", "ventricular arrhythmia", "sudden cardiac death", and "aortic valve replacement". Both landmark historical studies and modern investigations utilizing advanced monitoring techniques were included to provide a complete evolution of the understanding. Results: The prevalence of ventricular ectopy and non-sustained ventricular tachycardia increases with AS severity and symptom onset. Left ventricular hypertrophy, myocardial fibrosis, altered electrophysiological properties, and ischemia create the arrhythmogenic substrate. Risk factors include the male sex, concomitant aortic regurgitation, elevated filling pressures, and syncope. Diagnostic approaches range from standard electrocardiography to continuous monitoring and advanced imaging. Management centers on timely valve intervention, with medical therapy serving primarily as a bridge to AVR. Conclusions: Ventricular arrhythmias represent a consequence of valvular pathology in severe AS rather than an independent entity. Their presence signals advanced disease and a heightened risk for adverse outcomes. Multidisciplinary management with vigilant monitoring and prompt surgical referral is essential. Understanding this relationship enables clinicians to better identify high-risk patients requiring urgent intervention before life-threatening arrhythmic events occur.

Department of Cardiology Agel Hospital Trinec Podlesi 739 61 Trinec Czech Republic

Faculty of Medicine University of Ostrava 701 03 Ostrava Czech Republic

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Sorgato A., Faggiano P., Aurigemma G.P., Rusconi C., Gaasch W.H. Ventricular Arrhythmias in Adult Aortic Stenosis: Prevalence, Mechanisms, and Clinical Relevance. Chest. 1998;113:482–491. doi: 10.1378/chest.113.2.482. PubMed DOI

Carabello B.A., Paulus W.J. Aortic Stenosis. Lancet Lond. Engl. 2009;373:956–966. doi: 10.1016/S0140-6736(09)60211-7. PubMed DOI

Radnic B., Radojevic N., Vucinic J., Duborija-Kovacevic N. The Association between Pro-Arrhythmic Agents and Aortic Stenosis in Young Adults: Is It Sufficient to Clarify the Sudden Unexpected Deaths? Cardiol. Young. 2017;27:929–935. doi: 10.1017/S1047951116001864. PubMed DOI PMC

Ross J., Braunwald E. Aortic Stenosis. Circulation. 1968;38:V-61. doi: 10.1161/01.CIR.38.1S5.V-61. PubMed DOI

Matthews A.W., Barritt D.W., Keen G.E., Belsey R.H. Preoperative Mortality in Aortic Stenosis. Heart. 1974;36:101–103. doi: 10.1136/hrt.36.1.101. PubMed DOI PMC

Chizner M.A., Pearle D.L., deLeon A.C. The Natural History of Aortic Stenosis in Adults. Am. Heart J. 1980;99:419–424. doi: 10.1016/0002-8703(80)90375-0. PubMed DOI

Wolfe R.R., Driscoll D.J., Gersony W.M., Hayes C.J., Keane J.F., Kidd L., O’Fallon W.M., Pieroni D.R., Weidman W.H. Arrhythmias in Patients with Valvar Aortic Stenosis, Valvar Pulmonary Stenosis, and Ventricular Septal Defect. Results of 24-Hour ECG Monitoring. Circulation. 1993;87:I89–101. PubMed

Urena M., Hayek S., Cheema A.N., Serra V., Amat-Santos I.J., Nombela-Franco L., Ribeiro H.B., Allende R., Paradis J.-M., Dumont E., et al. Arrhythmia Burden in Elderly Patients with Severe Aortic Stenosis as Determined by Continuous Electrocardiographic Recording: Toward a Better Understanding of Arrhythmic Events after Transcatheter Aortic Valve Replacement. Circulation. 2015;131:469–477. doi: 10.1161/CIRCULATIONAHA.114.011929. PubMed DOI

Tempio D., Pruiti G.P., Conti S., Romano S.A., Tavano E., Capodanno D., Liotta C., Di Grazia A., Tamburino C., Calvi V. Ventricular Arrhythmias in Aortic Valve Stenosis before and after Transcatheter Aortic Valve Implantation. Europace. 2015;17:1136–1140. doi: 10.1093/europace/euu362. PubMed DOI

Taniguchi T., Morimoto T., Shiomi H., Ando K., Kanamori N., Murata K., Kitai T., Kawase Y., Izumi C., Kato T., et al. Sudden Death in Patients with Severe Aortic Stenosis: Observations From the CURRENT AS Registry. J. Am. Heart Assoc. Cardiovasc. Cerebrovasc. Dis. 2018;7:e008397. doi: 10.1161/JAHA.117.008397. PubMed DOI PMC

Nemes A., Forster T., Kovács Z., Thury A., Ungi I., Csanády M. The Effect of Aortic Valve Replacement on Coronary Flow Reserve in Patients with a Normal Coronary Angiogram. Herz. 2002;27:780–784. doi: 10.1007/s00059-002-2355-x. PubMed DOI

Meimoun P., Germain A.L., Elmkies F., Benali T., Boulanger J., Espanel C., Clerc J., Zemir H., Luycx-Bore A., Tribouilloy C. Factors Associated with Noninvasive Coronary Flow Reserve in Severe Aortic Stenosis. J. Am. Soc. Echocardiogr. Off. Publ. Am. Soc. Echocardiogr. 2012;25:835–841. doi: 10.1016/j.echo.2012.05.020. PubMed DOI

Tosto G., Passaniti G., Gibiino F.A., Deste W., Indelicato A., Torrisi T., Bottaro G., Cannizzaro M.T., Tamburino C. Myocardial Fibrosis in Aortic Stenosis: Comparison between Clinical Data, Laboratory, Echocardiography, and Cardiac Magnetic Resonance. J. Cardiol. Cardiovasc. Med. 2023;8:051–058. doi: 10.29328/journal.jccm.1001153. DOI

Azevedo C.F., Nigri M., Higuchi M.L., Pomerantzeff P.M., Spina G.S., Sampaio R.O., Tarasoutchi F., Grinberg M., Rochitte C.E. Prognostic Significance of Myocardial Fibrosis Quantification by Histopathology and Magnetic Resonance Imaging in Patients with Severe Aortic Valve Disease. J. Am. Coll. Cardiol. 2010;56:278–287. doi: 10.1016/j.jacc.2009.12.074. PubMed DOI

Dweck M.R., Joshi S., Murigu T., Alpendurada F., Jabbour A., Melina G., Banya W., Gulati A., Roussin I., Raza S., et al. Midwall Fibrosis Is an Independent Predictor of Mortality in Patients with Aortic Stenosis. J. Am. Coll. Cardiol. 2011;58:1271–1279. doi: 10.1016/j.jacc.2011.03.064. PubMed DOI

Barone-Rochette G., Piérard S., De Meester De Ravenstein C., Seldrum S., Melchior J., Maes F., Pouleur A.-C., Vancraeynest D., Pasquet A., Vanoverschelde J.-L., et al. Prognostic Significance of LGE by CMR in Aortic Stenosis Patients Undergoing Valve Replacement. J. Am. Coll. Cardiol. 2014;64:144–154. doi: 10.1016/j.jacc.2014.02.612. PubMed DOI

Bhattacharyya S., Lloyd G. Mortality Whilst Waiting for Intervention in Symptomatic Severe Aortic Stenosis. Eur. Heart J. Qual. Care Clin. Outcomes. 2019;6:qcz043. doi: 10.1093/ehjqcco/qcz043. PubMed DOI

Gould K.L., Carabello B.A. Why Angina in Aortic Stenosis with Normal Coronary Arteriograms? Circulation. 2003;107:3121–3123. doi: 10.1161/01.CIR.0000074243.02378.80. PubMed DOI

Aro A.L., Anttonen O., Tikkanen J.T., Junttila M.J., Kerola T., Rissanen H.A., Reunanen A., Huikuri H.V. Intraventricular Conduction Delay in a Standard 12-Lead Electrocardiogram as a Predictor of Mortality in the General Population. Circ. Arrhythm. Electrophysiol. 2011;4:704–710. doi: 10.1161/CIRCEP.111.963561. PubMed DOI

Volk T., Noble P.J., Wagner M., Noble D., Ehmke H. Ascending Aortic Stenosis Selectively Increases Action Potential-Induced Ca2+ Influx in Epicardial Myocytes of the Rat Left Ventricle. Exp. Physiol. 2005;90:111–121. doi: 10.1113/expphysiol.2004.028712. PubMed DOI

De Ambroggi L., Francia P., De Ambroggi G. Repolarization Abnormalities and Arrhythmogenesis in Hypertrophic Myocardium. Anadolu Kardiyol. Derg. AKD Anatol. J. Cardiol. 2007;7((Suppl. 1)):71–72. PubMed

Ducceschi V., Sarubbi B., D’Andrea A., Liccardo B., Briglia N., Carozza A., Marmo J., Santangelo L., Iacono A., Cotrufo M. Increased QT Dispersion and Other Repolarization Abnormalities as a Possible Cause of Electrical Instability in Isolated Aortic Stenosis. Int. J. Cardiol. 1998;64:57–62. doi: 10.1016/S0167-5273(97)00334-3. PubMed DOI

Dweck M.R., Boon N.A., Newby D.E. Calcific Aortic Stenosis. J. Am. Coll. Cardiol. 2012;60:1854–1863. doi: 10.1016/j.jacc.2012.02.093. PubMed DOI

O’Mahony C., Jichi F., Pavlou M., Monserrat L., Anastasakis A., Rapezzi C., Biagini E., Gimeno J.R., Limongelli G., McKenna W.J., et al. A Novel Clinical Risk Prediction Model for Sudden Cardiac Death in Hypertrophic Cardiomyopathy (HCM Risk-SCD) Eur. Heart J. 2014;35:2010–2020. doi: 10.1093/eurheartj/eht439. PubMed DOI

Cambise N., Gnan E., Tremamunno S., Telesca A., Belmusto A., Tinti L., Di Renzo A., Aurigemma C., Burzotta F., Trani C., et al. Impact on Clinical Outcome of Ventricular Arrhythmias in Patients Undergoing Transcatheter Aortic Valve Implantation. J. Cardiovasc. Med. 2024;25:327–333. doi: 10.2459/JCM.0000000000001596. PubMed DOI PMC

Goliasch G., Kammerlander A.A., Nitsche C., Dona C., Schachner L., Öztürk B., Binder C., Duca F., Aschauer S., Laufer G., et al. Syncope: The Underestimated Threat in Severe Aortic Stenosis. JACC Cardiovasc. Imaging. 2019;12:225–232. doi: 10.1016/j.jcmg.2018.09.020. PubMed DOI

Francisco-Pascual J., Rodenas E., Belahnech Y., Rivas-Gándara N., Pérez-Rodon J., Santos-Ortega A., Benito B., Roca-Luque I., Cossio-Gil Y., Serra Garcia V., et al. Syncope in Patients with Severe Aortic Stenosis: More Than Just an Obstruction Issue. Can. J. Cardiol. 2021;37:284–291. doi: 10.1016/j.cjca.2020.04.047. PubMed DOI

Otto C.M., Nishimura R.A., Bonow R.O., Carabello B.A., Erwin J.P., Gentile F., Jneid H., Krieger E.V., Mack M., McLeod C., et al. 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e80, e91–e104. doi: 10.1161/CIR.0000000000000923. PubMed DOI

Burup Kristensen C., Jensen J.S., Sogaard P., Carstensen H.G., Mogelvang R. Atrial Fibrillation in Aortic Stenosis—Echocardiographic Assessment and Prognostic Importance. Cardiovasc. Ultrasound. 2012;10:38. doi: 10.1186/1476-7120-10-38. PubMed DOI PMC

Kubala M., De Chillou C., Bohbot Y., Lancellotti P., Enriquez-Sarano M., Tribouilloy C. Arrhythmias in Patients with Valvular Heart Disease: Gaps in Knowledge and the Way Forward. Front. Cardiovasc. Med. 2022;9:792559. doi: 10.3389/fcvm.2022.792559. PubMed DOI PMC

Martínez-Useros C., Tornos P., Montoyo J., Permanyer Miralda G., Alijarde M., García Del Castillo H., Moreno V., Soler-Soler J. Ventricular Arrhythmias in Aortic Valve Disease: A Further Marker of Impaired Left Ventricular Function. Int. J. Cardiol. 1992;34:49–56. doi: 10.1016/0167-5273(92)90081-D. PubMed DOI

Gatzoulis K.A., Tsiachris D., Arsenos P., Archontakis S., Dilaveris P., Vouliotis A., Sideris S., Skiadas I., Kallikazaros I., Stefanadis C. Prognostic Value of Programmed Ventricular Stimulation for Sudden Death in Selected High Risk Patients with Structural Heart Disease and Preserved Systolic Function. Int. J. Cardiol. 2014;176:1449–1451. doi: 10.1016/j.ijcard.2014.08.068. PubMed DOI

Asmarats L., Nault I., Ferreira-Neto A.N., Muntané-Carol G., Del Val D., Junquera L., Paradis J.-M., Delarochellière R., Mohammadi S., Kalavrouziotis D., et al. Prolonged Continuous Electrocardiographic Monitoring Prior to Transcatheter Aortic Valve Replacement. JACC Cardiovasc. Interv. 2020;13:1763–1773. doi: 10.1016/j.jcin.2020.03.031. PubMed DOI

Zeppenfeld K., Tfelt-Hansen J., De Riva M., Winkel B.G., Behr E.R., Blom N.A., Charron P., Corrado D., Dagres N., De Chillou C., et al. 2022 ESC Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. Eur. Heart J. 2022;43:3997–4126. doi: 10.1093/eurheartj/ehac262. PubMed DOI

Redfors B., Pibarot P., Gillam L.D., Burkhoff D., Bax J.J., Lindman B.R., Bonow R.O., O’Gara P.T., Leon M.B., Généreux P. Stress Testing in Asymptomatic Aortic Stenosis. Circulation. 2017;135:1956–1976. doi: 10.1161/CIRCULATIONAHA.116.025457. PubMed DOI

Everett R.J., Clavel M.-A., Pibarot P., Dweck M.R. Timing of Intervention in Aortic Stenosis: A Review of Current and Future Strategies. Heart. 2018;104:2067–2076. doi: 10.1136/heartjnl-2017-312304. PubMed DOI PMC

Rosenhek R., Binder T., Porenta G., Lang I., Christ G., Schemper M., Maurer G., Baumgartner H. Predictors of Outcome in Severe, Asymptomatic Aortic Stenosis. N. Engl. J. Med. 2000;343:611–617. doi: 10.1056/NEJM200008313430903. PubMed DOI

Karatasakis’, ’George Clinical Features of Aortic Stenosis: The Need for Exercise Testing, a General Introduction. [(accessed on 2 March 2025)]. Available online: https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-18/clinical-features-of-aortic-stenosis-the-need-for-exercise-testing.

Pay L., Yumurtaş A.Ç., Tezen O., Çetin T., Keskin K., Eren S., Çinier G., Hayıroğlu M.İ., Çınar T., Tekkeşin A.İ. Effect of Ivabradine on Ventricular Arrhythmias in Heart Failure Patients with Reduced Ejection Fraction. Rev. Assoc. Médica Bras. 2023;69:e20230703. doi: 10.1590/1806-9282.20230703. PubMed DOI PMC

Bistola V., Arfaras-Melainis A., Polyzogopoulou E., Ikonomidis I., Parissis J. Inotropes in Acute Heart Failure: From Guidelines to Practical Use: Therapeutic Options and Clinical Practice. Card. Fail. Rev. 2019;5:133–139. doi: 10.15420/cfr.2019.11.2. PubMed DOI PMC

Ben-Dor I., Pichard A.D., Satler L.F., Goldstein S.A., Syed A.I., Gaglia M.A., Weissman G., Maluenda G., Gonzalez M.A., Wakabayashi K., et al. Complications and Outcome of Balloon Aortic Valvuloplasty in High-Risk or Inoperable Patients. JACC Cardiovasc. Interv. 2010;3:1150–1156. doi: 10.1016/j.jcin.2010.08.014. PubMed DOI