Indications for Surgical Aortic Valve Replacement

Abstract

EditorialOpen AccessThe average survival rate was 3 years after the onset of angina pectoris in patients with severe Aortic Stenosis (AS) [1]. The average survival rate after the onset of syncope in patients with severe AS was 3 years [1]. The average survival rate after the onset of heart failure in patients with severe AS was 1.5 to 2 years [1]. Patients with symptomatic severe valvular AS have a poor prognosis [1][2][3][4]. At the National Institutes of Health, 52% of patients with symptomatic severe valvular AS not operated on were dead at 5 years [1]. At 10-year followup, 90% of these patients were dead.At 4-year follow-up of patients aged 75 to 86 years in the Helsinki Aging Study, the incidence of cardiovascular mortality was 62% in patients with severe AS [2]. At 4-year follow-up, the incidence of total mortality was 76% in patients with severe AS [2].In a prospective study, at 19-month follow-up (range 2 to 36 months), 90% of 30 patients with heart failure associated with unoperated severe AS and a normal left ventricular ejection fraction were dead [3]. At 13-month follow-up (range 2 to 24 months), 100% of 18 patients with heart failure associated with unoperated severe AS and an abnormal left ventricular ejection fraction were dead [3]. In a prospective study, at 20-month follow-up of 40 elderly patients with severe AS, heart failure, syncope, or angina pectoris was present in 36 of 37 patients (97%) who developed new coronary events and in none of 3 patients (0%) without new coronary events [4].Surgical Aortic Valve Replacement (AVR) is the procedure of choice for symptomatic patients with severe AS (an aortic valve area less than 1.0 cm 2 ) with a Class I indication [5]. Other Class I indications for AVR in patients with severe AS include 2) patients undergoing coronary artery bypass graft surgery, 3) patients undergoing surgery on the aorta or other heart valves, and 4) patients with a left ventricular ejection fraction less than 50% [5]. Patients with moderate AS undergoing coronary artery bypass graft surgery or surgery on the aorta or other heart valves have a Class IIa indication for AVR [5].Although the American College of Cardiology/American Heart Association guidelines does not recommend AVR in patients with asymptomatic severe AS and normal left ventricular ejection fraction, there are data suggesting otherwise [6][7][8][9][10]. Pai et al. [6] found in their database that 99 of 338 patients (29%) mean age 71 years, with asymptomatic severe AS had AVR during 3.5-year follow-up. Survival at 1, 2, and 5 years was 67%, 56%, and 38%, respectively for nonoperated patients and 94%, 93%, and 90%, respectively for those who had AVR. In the unoperated group, beta blocker use significantly reduced mortality by 48%, and statin use significantly reduced mortality by 48% [6].Severe asymptomatic AS was present in 622 patients, mean age 72 years, at the Mayo Clinic [7]. Of the 622 patients, 166 (27%) developed symptoms and had AVR. Another 97 patients (16%) had AVR in the absence of symptoms. At 3-year fol...

Comparing characteristics and clinical and echocardiographic outcomes in low‐flow vs normal‐flow severe aortic stenosis with preserved ejection fraction in an Asian population

“…However, recent studies have cast doubt on whether the low‐flow state truly portends a poorer prognosis . Studies also appear conflicted on the impact of surgery on these patients …”

“…8 Studies also appear conflicted on the impact of surgery on these patients. 9,10 Furthermore, reduced LVEF to <50% is an ACC/AHA class I indication for aortic valve replacement (AVR), even in the absence of symptoms. 11,12 To date, no study has yet examined the deterioration of LVEF over time in patients with low-flow compared to normal-flow severe AS.…”

Predicting changes in flow category in patients with severe aortic stenosis and preserved left ventricular ejection fraction on medical therapy

“…In addition, some studies have demonstrated that low‐flow severe AS behaved more like moderate AS. Furthermore, the timing and role of surgery in these patients remained unclear . Therefore, the natural history and progression of severe AS in various flow categories remained to be better understood.…”

Aortic Stenosis Prognostication in Patients With Type 2 Diabetes: Protocol for Testing and Validation of a Biomarker-Derived Scoring System

“…Advanced stages of AS warrants surgical aortic valve replacement (AVR) [4]. Despite the aid of echocardiographic parameters allowing for delineation of mild, moderate and severe aortic stenosis, the single prevailing indication for surgical intervention is the severity of symptoms [5].…”