Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry

Abstract

Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) registry was a large Japanese multicentre retrospective registry of consecutive patients with severe aortic stenosis (AS) before introduction of transcatheter aortic valve implantation. We sought to overview the data from the CURRENT AS registry to discuss the three major contemporary issues related to clinical practice in patients with severe AS: (1) under-referral/underuse of surgical aortic valve replacement (SAVR) in symptomatic patients with severe AS, (2) management of asymptomatic patients with severe AS and (3) management of patients with low-gradient severe aortic stenosis (LG-AS). First, despite the dismal prognosis of symptomatic patients with severe AS, SAVR, including those performed during follow-up, was reported to be underused. In the CURRENT AS registry, overall 53% of symptomatic patients underwent aortic valve replacement (AVR) during follow-up. Second, we reported that compared with conservative strategy, initial AVR strategy was associated with lower risk of all-cause death and heart failure hospitalisation in asymptomatic patients with severe AS. Although current recommendations for AVR are mainly dependent on the patient symptoms, some patients may not complain of any symptom because of their sedentary lifestyle. We also reported several important objective factors associated with worse clinical outcomes in asymptomatic patients with severe AS for risk stratification. Finally, initial AVR strategy was associated with better long-term clinical outcomes than conservative strategy in both patients with high-gradient AS and patients with LG-AS. The favourable effect of initial AVR strategy was also seen in patients with LG-AS with left ventricular ejection fraction of ≥50%.

Management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis

“…Additionally, the presence of left ventricular impairment represents a high-risk feature that mandates intervention in these patients. Still, some argue that it may already be too late when the LVEF drops 21 22. So far, there has been an ongoing debate with studies demonstrating a low risk of death in patients with asymptomatic aortic stenosis unless there is very severe aortic stenosis or signs of rapid progression or myocardial impairment 23 24.…”

Exercise Training for Patients With Severe Aortic Stenosis in a Convalescent Rehabilitation Ward ― A Retrospective Cohort Study ―

“…The prognosis for symptomatic AS is typically poor. 14 The cumulative 1-year incidence of aortic valve-related death and heart failure is significantly higher in patients with than without symp-was considered statistically significant. All statistical analyses were performed using JMP 14.0 (SAS Institute Inc., Cary, NC, USA).…”

Left ventricular ejection fraction: clinical, pathophysiological, and technical limitations

“…To support this view, clinical studies and meta-analyses have shown that survival in patients with AS and no or minimal symptoms at diagnosis is poor when LVEF is <60% (109)(110)(111)(112). Moreover, in asymptomatic AS patients with LVEF >60%, early AVR has been shown to be associated with reduced all-cause mortality, acute myocardial infarction, stroke, and hospitalization for HF, compared with patients treated with conservative management and AVR deferred after symptoms onset (113)(114)(115)(116)(117). To avoid the latter, alternative parameters, such as GLS, may be more useful to identify early myocardial function changes and the optimal timing for AVR (118,119).…”