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Review
. 2023 Mar;21(3):193-210.
doi: 10.1080/14779072.2023.2186853. Epub 2023 Mar 29.

Heart failure and excess mortality after aortic valve replacement in aortic stenosis

Nikoo Aziminia  1   2 , Christian Nitsche  1   2 , Rok Mravljak  2 , Jonathan Bennett  1   2 , George D Thornton  1   2 , Thomas A Treibel  1   2
Affiliations
Review

Heart failure and excess mortality after aortic valve replacement in aortic stenosis

Nikoo Aziminia et al. Expert Rev Cardiovasc Ther. 2023 Mar.

Abstract

Introduction: In aortic stenosis (AS), the heart transitions from adaptive compensation to an AS cardiomyopathy and eventually leads to decompensation with heart failure. Better understanding of the underpinning pathophysiological mechanisms is required in order to inform strategies to prevent decompensation.

Areas covered: In this review, we therefore aim to appraise the current pathophysiological understanding of adaptive and maladaptive processes in AS, appraise potential avenues of adjunctive therapy before or after AVR and highlight areas of further research in the management of heart failure post AVR.

Expert opinion: Tailored strategies for the timing of intervention accounting for individual patient's response to the afterload insult are underway, and promise to guide better management in the future. Further clinical trials of adjunctive pharmacological and device therapy to either cardioprotect prior to intervention or promote reverse remodeling and recovery after intervention are needed to mitigate the risk of heart failure and excess mortality.

Keywords: Aortic stenosis; aortic valve replacement; heart failure; left ventricular hypertrophy; myocardial fibrosis.

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Conflict of interest statement

TA Treibel is funded by British Heart Foundation intermediate fellowships (FS/19/35/34374). TA Treibel is directly and indirectly supported by the University College London Hospitals NIHR Biomedical Research Centre and Biomedical Research Unit at Barts Hospital, respectively. GD Thornton is supported by BHF Clinical Research Training Fellowship (FS/CRTF/21/24128). The authors have no other 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 apart from those disclosed.

Figures

Figure 1.
Figure 1.
Contributors to heart failure after aortic valve replacement. AS = aortic stenosis, AV = aortic valve, MV = mitral valve, TV = tricuspid valve, ROS = reactive oxygen species, CPB = cardiopulmonary bypass, HAVB = higher degree atrioventricular block, LV = left ventricle, RV = right ventricle, VT = ventricular tachycardia
Figure 2.
Figure 2.
Potential strategies to mitigate excess morbidity and mortality associated with aortic stenosis. Optimal timing and tailoring of valve intervention to the patient with aortic valve replacement, with appropriate pre- and post-intervention modifications to treatment, may improve outcomes for patients with AS. AS = aortic stenosis, AVR = aortic valve replacement, TAVI = transcatheter aortic valve replacement, SAVR = surgical aortic valve replacement, VHD = valvular heart disease.
See this image and copyright information in PMC

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