Do all patients with asymptomatic severe aortic stenosis need treatment?

ABSTRACT

Introduction

Although guidelines recommend a watchful waiting strategy for patients with asymptomatic severe aortic stenosis, there have been considerable advancements in surgical and anesthetic techniques along with the success of transcatheter aortic valve replacement (AVR) as a viable alternative to surgical AVR. Inevitably, these developments have raised questions as to whether or not there is still merit in waiting for symptoms to ensue before treatment may be offered to these patients.

Area covered

The principal purpose of this paper is to review the data supporting earlier intervention in patients with asymptomatic severe aortic stenosis, and to project the implications these and other ongoing trials will have on indications for AVR in asymptomatic patients in the future.

Expert opinion

The threshold for intervention in certain subgroups of asymptomatic patients with severe AS has already been lowered. The next frontier will inevitably be determining whether all patients with severe AS should undergo AVR irrespective of their symptomatic status.

KEYWORDS:

• Aortic stenosis
• asymptomatic
• treatment
• surgical aortic valve replacement
• transcatheter aortic valve replacement
• natural history

Article highlights

• Asymptomatic severe AS may not carry as favorable prognosis as previously thought.

• Two randomized trials demonstrated survival benefit with early surgical approach in comparison to watchful waiting.

• Whether the benefits of early surgery showed in the two randomized trials can be extrapolated to subgroups of asymptomatic patients with AS, such as paradoxical low-flow, low-gradient AS is unknown.

• Ongoing work is being conducted to identify prognostic imaging biomarkers that relate to each of these categories in an attempt to better predict the optimal time for surgery before irreversible structural changes occur to the heart.

• Before TAVR can be accepted as a treatment for all patients with severe AS irrespective of age and risk, it will need to demonstrate comparable long-term durability (≥10 years) to surgically implanted prosthetic valves.

• Any decisions regarding treatment should be taken following consideration an individual patient’s cardiovascular risk factors and the patient should be involved in the clinical decisions regarding their care.

• The next frontier will inevitably be determining whether all patients with severe AS should undergo AVR irrespective of their symptomatic status.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.