Severe Aortic Stenosis Should Not Be Operated on Before Symptom Onset

> “If it ain't broke, don't fix it.” > > —Thomas Bertram Lance in Nation's Business , May 1977 Aortic valve stenosis resulting from calcific thickening of a previously normal 3-cusp aortic valve or a congenitally bicuspid aortic valve is a common clinical condition in developed countries, and its prevalence is continuing to increase with aging of the population.1,2 In the Cardiovascular Health Study, which involved 5201 men and women >65 years of age, the prevalence of aortic stenosis was 1.3% in subjects 65 to 75 years of age, 2.4% in subjects 75 to 85 years of age, and 4% in subjects >85 years of age.3 The precise mechanisms involved in the pathophysiology of aortic stenosis and its progression are incompletely understood, but advancing age and atherosclerosis-related risk factors have been implicated in the process.4 In fact, atherosclerotic coronary artery disease is present in nearly 50% of patients with aortic stenosis.5 Studies of valve pathology have suggested a potential role for dyslipidemia, inflammation, and angiogenesis in the process, but pharmacological therapies using statins to reduce dyslipidemia and associated inflammatory processes have yielded inconsistent but largely negative results in terms of reducing the rate of progression of aortic stenosis.6–10 Thus, in the absence of specific and effective disease-modifying medical therapies, surgical aortic valve replacement has been and continues to be the cornerstone of management of severe aortic stenosis. There is general agreement among physicians and surgeons that when severe aortic stenosis is accompanied by 1 or more symptoms, such as chest pain, syncope or near syncope, resuscitated sudden death, shortness of breath, fatigue, effort intolerance, or left ventricular (LV) dysfunction, aortic valve replacement is recommended because of well-established dismal outcome (≈50% mortality within 3 years) in unoperated symptomatic cases and overall excellent surgical outcomes with relatively low perioperative mortality and morbidity even among octogenarians …

[1]  L. Køber,et al.  Clinical Implications of Electrocardiographic Left Ventricular Strain and Hypertrophy in Asymptomatic Patients With Aortic Stenosis: The Simvastatin and Ezetimibe in Aortic Stenosis Study , 2012, Circulation.

[2]  R. Davidoff,et al.  Low-flow/low-gradient aortic stenosis. , 2011, Circulation.

[3]  M. Henein,et al.  Challenges in the management of severe asymptomatic aortic stenosis. , 2011, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[4]  A. Kobori,et al.  Clinical outcomes in non-surgically managed patients with very severe versus severe aortic stenosis , 2011, Heart.

[5]  P. Scuffham,et al.  Quality-of-Life Implications of Immediate Surgery and Watchful Waiting in Asymptomatic Aortic Stenosis: A Decision-Analytic Model , 2011, Circulation. Cardiovascular quality and outcomes.

[6]  Stuart J Pocock,et al.  Transcatheter versus surgical aortic-valve replacement in high-risk patients. , 2011, The New England journal of medicine.

[7]  D. Newby,et al.  Managing the asymptomatic patient with severe aortic stenosis: randomised controlled trials of early surgery are overdue , 2011, Heart.

[8]  J. Chambers,et al.  Outcome of Patients With Low-Gradient “Severe” Aortic Stenosis and Preserved Ejection Fraction , 2011, Circulation.

[9]  W. Keeling,et al.  Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery , 2011 .

[10]  L. Tarantini,et al.  Prognostic effect of inappropriately high left ventricular mass in asymptomatic severe aortic stenosis , 2010, Heart.

[11]  J. Daubert,et al.  Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay , 2010, Heart.

[12]  J. Chambers,et al.  Treadmill exercise in apparently asymptomatic patients with moderate or severe aortic stenosis: relationship between cardiac index and revealed symptoms , 2010, Heart.

[13]  S. Yun,et al.  Early Surgery Versus Conventional Treatment in Asymptomatic Very Severe Aortic Stenosis , 2010, Circulation.

[14]  C. Otto,et al.  Risk stratification of patients with aortic stenosis. , 2010, European heart journal.

[15]  M. Schemper,et al.  Natural History of Very Severe Aortic Stenosis , 2010, Circulation.

[16]  R. Bonow,et al.  The emerging role of exercise testing and stress echocardiography in valvular heart disease. , 2009, Journal of the American College of Cardiology.

[17]  Claire Duvernoy,et al.  Evaluation of Patients With Severe Symptomatic Aortic Stenosis Who Do Not Undergo Aortic Valve Replacement: The Potential Role of Subjectively Overestimated Operative Risk , 2009, Circulation. Cardiovascular quality and outcomes.

[18]  P. Pibarot,et al.  Usefulness of the valvuloarterial impedance to predict adverse outcome in asymptomatic aortic stenosis. , 2009, Journal of the American College of Cardiology.

[19]  A. DeMaria,et al.  Impact of impaired myocardial deformations on exercise tolerance and prognosis in patients with asymptomatic aortic stenosis. , 2009, European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology.

[20]  J. Bergler-Klein.  Natriuretic peptides in the management of aortic stenosis , 2009, Current cardiology reports.

[21]  Sean M. O'Brien,et al.  Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database. , 2009, The Journal of thoracic and cardiovascular surgery.

[22]  J. Chambers,et al.  Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis. , 2008, The New England journal of medicine.

[23]  S. Rahimtoola.  Valvular heart disease: a perspective on the asymptomatic patient with severe valvular aortic stenosis. , 2008, European heart journal.

[24]  P. Pibarot,et al.  Paradoxical Low-Flow, Low-Gradient Severe Aortic Stenosis Despite Preserved Ejection Fraction Is Associated With Higher Afterload and Reduced Survival , 2007, Circulation.

[25]  J. Zamorano,et al.  Rosuvastatin affecting aortic valve endothelium to slow the progression of aortic stenosis. , 2007, Journal of the American College of Cardiology.

[26]  Helmut Baumgartner,et al.  Guidelines on the management of valvular heart disease The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology , 2007 .

[27]  J. Borer,et al.  The epidemiology of valvular heart disease: a growing public health problem. , 2006, Heart failure clinics.

[28]  J. Gardin,et al.  Burden of valvular heart diseases: a population-based study , 2006, The Lancet.

[29]  C. Otto,et al.  Valvular aortic stenosis: disease severity and timing of intervention. , 2006, Journal of the American College of Cardiology.

[30]  M. Simon,et al.  Prognostic Importance of Quantitative Exercise Doppler Echocardiography in Asymptomatic Valvular Aortic Stenosis , 2005, Circulation.

[31]  H. Rimington,et al.  Exercise testing to stratify risk in aortic stenosis. , 2005, European heart journal.

[32]  K. Bailey,et al.  Outcome of 622 Adults With Asymptomatic, Hemodynamically Significant Aortic Stenosis During Prolonged Follow-Up , 2005, Circulation.

[33]  R. Prescott,et al.  A randomized trial of intensive lipid-lowering therapy in calcific aortic stenosis. , 2005, The New England journal of medicine.

[34]  A. Richards,et al.  Usefulness of serial measurement of N-terminal pro-brain natriuretic peptide plasma levels in asymptomatic patients with aortic stenosis to predict symptomatic deterioration. , 2005, The American journal of cardiology.

[35]  C. Otto,et al.  Targeted therapy to prevent progression of calcific aortic stenosis. , 2004, Circulation.

[36]  H. Baumgartner,et al.  Natriuretic Peptides Predict Symptom-Free Survival and Postoperative Outcome in Severe Aortic Stenosis , 2004, Circulation.

[37]  D. Horstkotte,et al.  Influence of atypical symptoms and electrocardiographic signs of left ventricular hypertrophy or ST-segment/T-wave abnormalities on the natural history of otherwise asymptomatic adults with moderate to severe aortic stenosis: preliminary communication. , 2004, The Journal of heart valve disease.

[38]  Volkmar Falk,et al.  Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. , 2003, The Annals of thoracic surgery.

[39]  A. Bloch,et al.  Value of exercise testing to evaluate the indication for surgery in asymptomatic patients with valvular aortic stenosis. , 2002, The Journal of heart valve disease.

[40]  M. Lauer,et al.  Effect of Hydroxymethylglutaryl Coenzyme A Reductase Inhibitors on the Progression of Calcific Aortic Stenosis , 2001, Circulation.

[41]  K. E. Werner,et al.  Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing , 2001, Heart.

[42]  W. Aronow,et al.  Association of coronary risk factors and use of statins with progression of mild valvular aortic stenosis in older persons. , 2001, The American journal of cardiology.

[43]  M. Schemper,et al.  Predictors of outcome in severe, asymptomatic aortic stenosis. , 2000, The New England journal of medicine.

[44]  C M Otto,et al.  Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. , 1997, Circulation.

[45]  K. Bailey,et al.  Natural history of moderate aortic stenosis. , 1991, Journal of the American College of Cardiology.

[46]  K. Bailey,et al.  The natural history of adults with asymptomatic, hemodynamically significant aortic stenosis. , 1990, Journal of the American College of Cardiology.

[47]  D. Kaiser,et al.  Comparison of outcome of asymptomatic to symptomatic patients older than 20 years of age with valvular aortic stenosis. , 1988, The American journal of cardiology.

[48]  Franz Schwarz,et al.  The Effect of Aortic Valve Replacement on Survival , 1982, Circulation.

[49]  M. A. Chizner,et al.  The natural history of aortic stenosis in adults. , 1980, American heart journal.

[50]  B. Carabello,et al.  Aortic stenosis , 2018, Rapid Cardiac Care.