Calcific Aortic Valve Stenosis: A Focal Disease in Older and Complex Patients-What Could Be the Best Time for an Appropriate Interventional Treatment?

Abstract

Calcific aortic stenosis (CAS) is a newly emerging pandemic in elderly individuals due to the aging of the population in the world. Surgical Aortic Valve Replacement (SAVR) and Transcatheter Aortic Valve Replacement (TAVR) are the cornerstone of the management of severe aortic stenosis accompanied by one or more symptoms. Moreover, an appropriate interventional treatment of CAS, in elderly patients, is a very complex decision for heart teams, to avoid bad outcomes such as operative mortality, cardiovascular and all-cause death, hospitalization for heart failure, worsening of quality of life. In fact, CAS in the elderly is not only a focal valve disease, but a very complex clinical picture with different risk factors and etiologies, differing underlying pathophysiology, large phenotypic heterogeneity in a context of subjective biological, phenotypic and functional aging until frailty and disability. In this review, we analyzed separately and in a more integrated manner, the natural and prognostic histories of the progression of aortic stenosis, the phenotypes of myocardial damage and heart failure, within the metrics and aging trajectory. The aim is to suggest, during the clinical timing of valve disease, the best interval time for an appropriate and effective interventional treatment in each older patient, beyond subjective symptoms by integration of clinical, geriatric, chemical, and advanced imaging biomarkers.

Keywords: appropriate interventional treatment; biomarkers; management of severe aortic stenosis; older patient.

Figure 1

Trajectories of the natural histories of aortic stenosis, heart failure and frailty, within the aging process in older patient candidates for interventional treatment of CAS with heart failure and a preserved ejection fraction (HFpEF). The two vertical dotted lines identify an ideal time for an appropriate interventional treatment in older patients.

Figure 2

A strategy of multidimensional evaluation during clinical surveillance in elderly patients with calcific aortic stenosis to identify the appropriate time for interventional treatment.