Ventricular Arrhythmias in Severe Aortic Stenosis Prior to Aortic Valve Replacement: A Literature Review

Abstract

Background and Objectives: Aortic stenosis (AS) is a frequent valvular disease characterized by the obstruction of left ventricular outflow. The resulting hemodynamic and structural changes create an arrhythmogenic substrate, with sudden cardiac death (SCD) often caused by ventricular arrhythmias (VAs) being a feared complication. This review examines the relationship between severe AS and VA, detailing the epidemiology, pathophysiological mechanisms, risk factors, and management approaches prior to aortic valve replacement (AVR). Materials and Methods: We conducted a comprehensive narrative review of the historical and contemporary literature investigating ventricular arrhythmias in severe aortic stenosis. Literature searches were performed in PubMed, MEDLINE, and Scopus databases using keywords, including "aortic stenosis", "ventricular arrhythmia", "sudden cardiac death", and "aortic valve replacement". Both landmark historical studies and modern investigations utilizing advanced monitoring techniques were included to provide a complete evolution of the understanding. Results: The prevalence of ventricular ectopy and non-sustained ventricular tachycardia increases with AS severity and symptom onset. Left ventricular hypertrophy, myocardial fibrosis, altered electrophysiological properties, and ischemia create the arrhythmogenic substrate. Risk factors include the male sex, concomitant aortic regurgitation, elevated filling pressures, and syncope. Diagnostic approaches range from standard electrocardiography to continuous monitoring and advanced imaging. Management centers on timely valve intervention, with medical therapy serving primarily as a bridge to AVR. Conclusions: Ventricular arrhythmias represent a consequence of valvular pathology in severe AS rather than an independent entity. Their presence signals advanced disease and a heightened risk for adverse outcomes. Multidisciplinary management with vigilant monitoring and prompt surgical referral is essential. Understanding this relationship enables clinicians to better identify high-risk patients requiring urgent intervention before life-threatening arrhythmic events occur.

Keywords: aortic stenosis; aortic valve disease; aortic valve replacement; sudden death; surgery; ventricular arrhythmia.

Figure 1

Pathophysiological mechanisms. Pathophysiological mechanisms of ventricular arrhythmias in severe aortic stenosis. Abbreviations: LVH, left ventricular hypertrophy; LVEDP, left ventricular end-diastolic pressure; PCWP, pulmonary capillary wedge pressure; LBBB, left bundle branch block; RBBB, right bundle branch block; AVB, atrioventricular block; APD, action potential duration; SCD, sudden cardiac death.

Figure 2

Risk factors and prognostic implications. Risk factors and prognostic implications of ventricular arrhythmias in severe aortic stenosis. Abbreviations: LVEDP, left ventricular end-diastolic pressure; NSVT, nonsustained ventricular tachycardia; PVCs, premature ventricular contractions; SCD, sudden cardiac death; SAVR, surgical aortic valve replacement; TAVR, transcatheter aortic valve replacement.