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Management of asymptomatic severe aortic stenosis: is aortic valve replacement indicated?

Nature Clinical Practice Cardiovascular Medicine volume 5, pages 608–609 (2008)Cite this article

The natural history of aortic stenosis (AS) is characterized by a long latency period, during which compensatory left ventricular (LV) hypertrophy develops as obstruction insidiously progresses. Thus, it is only late during the natural history of the disease that symptoms appear. Once the patient develops the classic symptom triad of angina, syncope, and heart failure, death is imminent unless the obstruction is removed. With increases in life expectancy, AS in older individuals is seen clinically with increasing frequency. Aortic valve disease is now the third most common cause of cardiovascular morbidity, and aortic valve replacement (AVR) for AS has become the second most common cardiac surgical procedure. Simultaneously, the mean age of patients undergoing AVR for AS has increased.1 An estimated 3–5% of individuals worldwide aged 75 years or older have clinically-significant AS, half of whom are asymptomatic.

The risks associated with asymptomatic AS were once thought to be low. A study from our institution, published in 1990, demonstrated that survival of asymptomatic patients with severe AS during a mean follow-up of 20 months was similar to that of an age-matched and sex-matched reference group from life-tables.2 More recent data with longer follow-up, however, indicate that survival of the asymptomatic patient might indeed be reduced. Among 622 asymptomatic patients with severe AS (peak aortic velocity assessed by Doppler echocardiography, ≥4 m/s) who did not undergo AVR at the initial evaluation, only 33% remained free of cardiac symptoms after a follow-up of 5.4 ± 4.0 years.3 Furthermore, during follow-up, there were 265 (42.6%) deaths, of which 117 (18.8%) were cardiac related. Importantly, 90 patients (14.5%) developed symptoms, but did not undergo AVR because they did not return for follow-up, refused the operation, or had developed clinically-significant comorbidities that made them ineligible for surgery. Moreover, even among patients who remained asymptomatic, there was a small but definite risk of sudden death, estimated at 1% per year. The severity of AS, as assessed by Doppler echocardiography, was predictive of symptom development, mortality and cardiac events—including cardiac death and AVR—during follow-up.3,4,5 There was, however, no definite cutoff value for peak aortic velocity, mean gradient, or aortic valve area that identified with certainty patients at risk of death or imminent symptoms.3,4 Similarly, the rate of stenosis progression, as reflected by the rate of increase in the aortic velocity, was predictive of the development of symptoms or mortality, but there was broad variability and overlap between patient groups.5 Although age, chronic renal failure, diabetes mellitus, decreased LV ejection fraction, LV hypertrophy, and inactivity also predicted development of symptoms and mortality among patients with asymptomatic, severe AS,3,6 the omission of AVR surgery had the greatest impact on late mortality.6 On the basis of this evidence, namely that the risks associated with severe AS are considerable, and because the methods of identifying patients at highest risk are imperfect, we believe that AVR should be considered in all asymptomatic patients with severe AS.

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References

  1. Roberts WC et al. (2005) Comparison of valve structure, valve weight, and severity of the valve obstruction in 1,849 patients having isolated aortic valve replacement for aortic valve stenosis (with or without associated aortic regurgitation) studied at 3 different medical centers in 2 different time periods. Circulation 112: 3919–3929

    Article  Google Scholar 

  2. Pellikka PA et al. (1990) The natural history of adults with asymptomatic, hemodynamically significant aortic stenosis. J Am Coll Cardiol 15: 1012–1017

    Article  CAS  Google Scholar 

  3. Pellikka PA et al. (2005) Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation 111: 3290–3295

    Article  Google Scholar 

  4. Otto CM et al. (1997) Prospective study of asymptomatic valvular aortic stenosis: clinical, echocardiographic, and exercise predictors of outcome. Circulation 95: 2262–2270

    Article  CAS  Google Scholar 

  5. Rosenhek et al. (2000) predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med 343: 611–617

    Article  CAS  Google Scholar 

  6. Brown ML et al. (2008) The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis. J Thorac Cardiovasc Surg 135: 308–315

    Article  Google Scholar 

  7. Society of Thoracic Surgeons (online 2006) Executive summary: STS Fall 2006 Report [http://www.sts.org/documents/pdf/STS-ExecutiveSummaryFall2006- REVISED.pdf] (accessed 13 June 2008)

  8. Connolly HM et al. (1997) Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction: prognostic indicators. Circulation 95: 2395–2400

    Article  CAS  Google Scholar 

  9. Asimakopoulos G et al. (1997) Aortic valve replacement in patients 80 years of age and older: survival and cause of death based on 1,100 cases: collective results from the UK Heart valve registry. Circulation 96: 3403–3408

    Article  CAS  Google Scholar 

  10. Hammermeister K et al. (2000) Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol 36: 1152–1158

    Article  CAS  Google Scholar 

  11. Bonow RO et al. (2006) ACC/AHA Guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 48: e1–e148

    Article  Google Scholar 

  12. Das P et al. (2005) Exercise testing to stratify risk in aortic stenosis. Eur Heart J 26: 1309–1313

    Article  Google Scholar 

  13. Sundt TM et al. (2000) Quality of life after aortic valve replacement at the age of >80 years. Circulation 102 (Suppl 3): III70–III74

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. PA Pellikka is Co-Director of the Echocardiography Laboratory at the Mayo Clinic and Professor of Medicine at the Mayo Clinic College of Medicine, Rochester, MN, USA.,

    Patricia A Pellikka

  2. TM Sundt is a Consultant at the Mayo Clinic and Professor of Surgery at the Mayo Clinic College of Medicine, Rochester, MN, USA.,

    Thoralf M Sundt

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  1. Patricia A Pellikka
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  2. Thoralf M Sundt
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Correspondence to Patricia A Pellikka.

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Competing interests

TM Sundt and colleagues in the Division of Cardiovascular Surgery at Mayo Clinic, Rochester, MN, USA have has received research support from AtriCure, Bolton Medical, Jarvik Heart, Medtronic, Sorin Group, St Jude Medical, Thoratec, Ventracor, and WL Gore & Associates. In addition, TM Sundt is a Consultant for Boston Scientific. PA Pellikka declared no competing interests.

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Pellikka, P., Sundt, T. Management of asymptomatic severe aortic stenosis: is aortic valve replacement indicated?. Nat Rev Cardiol 5, 608–609 (2008). https://doi.org/10.1038/ncpcardio1304

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