Asymptomatic Severe Aortic Valve Stenosis—When to Intervene: a Review of the Literature, Current Trials, and Guidelines
- 225 Downloads
Purpose of Review
The optimal treatment for asymptomatic patients with severe aortic valve stenosis (AS) is not clearly known. Here, we review the available data on the management of such patients.
Half of patients with severe AS are asymptomatic at the time of diagnosis, and are at risk for adverse events, including sudden cardiac death. A significant proportion of these patients develop AS-related symptoms within 1 or 2 years. Clinical and echocardiographic characteristics are predictors of poor outcomes and can guide treatment decisions. Several non-randomized studies and meta-analyses have suggested benefit from early AVR for asymptomatic severe AS, including improved all-cause, cardiovascular, and valve-related mortality. Based on the available information, current guidelines suggest aortic valve replacement in the presence of specific characteristic, including left ventricular dysfunction and very severe AS with significantly elevated gradients.
Although the available data suggests early AVR improves the clinical outcomes of these patients, most patients in current practice are managed conservatively. Six randomized trials are ongoing to better elucidate the ideal management of asymptomatic severe AS patients.
KeywordsAortic valve Severe aortic stenosis Asymptomatic Aortic valve replacement
Compliance with Ethical Standards
Conflict of Interest
Andrés M. Pineda and Todd L. Kiefer declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 12.•• Taniguchi T, Morimoto T, Shiommi H, Ando K, Kanamori N, Murata K, et al. Initial surgical versus conservative strategies in patients with asymptomatic severe aortic stenosis. J Am Coll Cardiol. 2015;66:2827–38 This study is the largest non-randomized study comparing early surgery versus conservative management in patients with asymptomatic severe aortic stenosis. CrossRefGoogle Scholar
- 28.Zito C, Salvia J, Cusma-Piccione M, Antonini-Canterin F, Lentini S, Oreto G, et al. Prognostic significance of valvuloarterial impedance and left ventricular longitudinal function in asymptomatic severe aortic stenosis involving three-cuspid valves. Am J Cardiol. 2011;108:1463–9.CrossRefGoogle Scholar
- 34.Lung B, Baron G, Butchart EG, Delahaye F, Gohlke-Barwolf C, Levang OW, et al. A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on valvular heart disease. Eur Heart J. 2033;24:1231–43.Google Scholar
- 35.• Genereux P, Stone GW, O’Hara PT, Marquis-Glavel G, Redfors B, Giustino G, et al. Natural history, diagnostic approaches and therapeutic strategies for patients with asymptomatic aortic stenosis. J Am Coll Cardiol. 2016;67:2263–88 Meta-analysis of available non-randomized studies comparing conservative management versus early AVR for asymptomatic patients with severe aortic stenosis. This meta-analysis showed improved outcomes with early AVR. CrossRefGoogle Scholar
- 40.Clavel MA, Messika-Zeitoun D, Pibarot P, Aggarval S, Malouf J, Araoz P, et al. The complex nature of discordant severe calcified artic valve disease grading: new insights from combined Doppler echocardiographic and computed tomographic study. J Am Coll Cardiol. 2013;62:2329–38.CrossRefGoogle Scholar
- 53.• Lim WY, Ramasamy A, Lloyd G, Bhattacharyya S. Meta-analysis of the impact of intervention versus symptom-driven management in asymptomatic severe aortic stenosis. Heart. 2017;103:268–72 Meta-analysis of available non-randomized studies comparing conservative management versus early AVR for asymptomatic patients with severe aortic stenosis. This meta-analysis showed no clear benefit from early AVR. CrossRefGoogle Scholar
- 55.Ledwoch J, Thiele H. Treatment of asymptomatic aortic stenosis: watchful waiting or early intervention? Heart. 2017;42:528–35.Google Scholar