Timing of Aortic Valve Intervention in the Management of Aortic Stenosis
- PMID: 39537272
- DOI: 10.1016/j.jcin.2024.08.046
Timing of Aortic Valve Intervention in the Management of Aortic Stenosis
Abstract
Aortic stenosis (AS) affects about 12% of people aged ≥75 years. Accumulating evidence on the prognostic importance of cardiac damage in patients with asymptomatic and less than severe AS supports the proposition of advancing aortic valve replacement (AVR) to earlier disease stages. Potential benefits of earlier treatment, including prevention of cardiac damage progression and reduced cardiovascular hospitalizations, need to be balanced against the earlier procedural risk and subsequent lifetime management after AVR. Two small, randomized trials indicate that early surgical AVR may improve survival in patients with asymptomatic severe AS, and observational data suggest that AVR may reduce mortality even in patients with moderate AS. A clear understanding of the pathophysiology of cardiac damage secondary to AS is needed to develop strategies to select patients for earlier AVR. Noninvasive imaging can detect early cardiac damage, and indices such as fibrosis, global longitudinal strain, and myocardial work index have potential use to guide stratification of patients for earlier AVR. Ongoing randomized trials are investigating the safety and efficacy of AVR for patients with asymptomatic severe AS and those with moderate AS who have symptoms/evidence of cardiac damage. Pathophysiological considerations and accumulating evidence from clinical studies that support earlier timing of AVR for AS will need to be corroborated by the results of these trials. This review aims to evaluate the evidence for earlier AVR, discuss strategies to guide stratification of patients who may benefit from this approach, highlight the relevant ongoing randomized trials, and consider the consequences of earlier intervention.
Keywords: aortic valve replacement; asymptomatic severe aortic stenosis; cardiac damage; moderate aortic stenosis.
Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.
Conflict of interest statement
Funding Support and Author Disclosures Dr Maznyczka is an EAPCI international structural fellow whose fellowship is funded by Edwards Lifesciences through EAPCI and not directly from Edwards Lifesciences. Dr Maznyczka has received travel grants from Edwards Lifesciences, Abbott, Boston Scientific, and Medtronic. Dr Prendergast has received lecture fees from Edwards Lifesciences; and has served on a trial steering committee for Medtronic and a data safety and monitoring committee for Valvosoft. Dr Windecker has received research and educational grants to his institution from Abbott, Amgen, AstraZeneca, BMS, Bayer, Biotronik, Boston Scientific, Cardinal Health, CardioValve, CSL Behring, Daiichi Sankyo, Edwards Lifesciences, Guerbet, InfraRedx, Johnson & Johnson, Medicure, Medtronic, Novartis, Polares, OrPha Suisse, Pfizer, Regeneron, Sanofi, Sinomed, Terumo, and V-Wave; serves as unpaid advisory board member and/or unpaid member of the steering/executive group of trials funded by Abbott, Abiomed, Amgen, Astra Zeneca, BMS, Boston Scientific, Biotronik, Cardiovalve, Edwards Lifesciences, Med Alliance, Medtronic, Novartis, Polares, Sinomed, V-Wave, and Xeltis, but has not received personal payments by pharmaceutical companies or device manufacturers; is a member of the steering/executive committee group of several investigator-initiated trials that receive funding by industry without impact on his personal remuneration; is an unpaid member of the Pfizer Research Award selection committee in Switzerland and of the Women as One Awards Committee; is member of the Clinical Study Group of the Deutsches Zentrum für Herz Kreislauf-Forschung and of the Advisory Board of the Australian Victorian Heart Institute; and is chairperson of the ESC Congress Program Committee and Associate Editor of JACC Cardiovascular Interventions. Dr Généreux has served as a consultant for Abbott Vascular, Abiomed, BioTrace Medical, Boston Scientific, CARANX Medical, Cardiovascular System Inc (PI Eclipse Trial), Edwards Lifesciences (PI EARLY-TAVR trial, PI PROGRESS trial), GE Healthcare, iRhythm Technologies, Medtronic, Opsens, Pi-Cardia, Puzzle Medical, Saranas, Shockwave, Siemens, Soundbite Medical Inc, Teleflex, and 4C Medical (PI feasibility study); has served as an advisor for Abbott Vascular, Abiomed, BioTrace Medical, Edwards Lifesciences, and Medtronic; has received speaker fees from Abbott Vascular, Abiomed, BioTrace Medical, Edwards Lifesciences, Medtronic, and Shockwave; has served as a proctor for and received an institutional research grant from Edwards Lifesciences, and has equity in Pi-Cardia, Puzzle Medical, Saranas, and Soundbite Medical Inc. Dr Hildick-Smith has served as an advisor/ proctor for Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott. Dr Bax has received speaker fees from Abbott Vascular, Edwards Lifesciences, and Omron. Dr Pilgrim has received research, travel, or educational grants to his institution without personal remuneration from Biotronik, Boston Scientific, Edwards Lifesciences, and ATSens; and has received speaker fees and consultancy fees to his institution from Biotronik, Boston Scientific, Edwards Lifesciences, Abbott, Medtronic, Biosensors, and Highlife. Dr Dweck has reported that he has no relationships relevant to the contents of this paper to disclose.
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