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Timing of intervention in aortic stenosis: a review of current and future strategies
  1. Russell James Everett1,
  2. Marie-Annick Clavel2,
  3. Philippe Pibarot2,
  4. Marc Richard Dweck1
  1. 1 BHF/Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
  2. 2 Department of Medicine, Quebec Heart and Lung Institute, Quebec, Canada
  1. Correspondence to Dr Russell James Everett, BHF/Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK; russell.everett{at}ed.ac.uk

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Learning objectives

  • To review the pathophysiology of fibrocalcific aortic stenosis, the myocardial response to pressure overload and current clinical guidelines concerning the timing of valve intervention.

  • To explore and to quantify the risks of earlier intervention in asymptomatic patients compared with the risks of a watchful waiting strategy.

  • To detail future potential strategies for deciding on timing of aortic valve intervention and current ongoing randomised controlled trials.

Introduction

Aortic stenosis (AS) is the most common valve disease requiring surgical intervention in high-income countries.1 It is characterised by progressive thickening, fibrosis and calcification of the leaflets leading to restriction and valve obstruction.2 The consequent increase in left ventricular afterload leads to a hypertrophic response of the left ventricle, normalising wall tension and maintaining cardiac output. However, with progressive valvular stenosis, this hypertrophic response eventually decompensates resulting in symptom development, heart failure and death.

With no medications proven to attenuate or reverse stenosis progression, the only available treatment is valve replacement. This should ideally be performed when the risks of the disease process (ie, sudden cardiac death, irreversible functional impairment and heart failure) outweigh those of intervention (ie, procedural risk, long-term complications and potential need for reoperation). However, we frequently lack robust evidence to make accurate assessments of such risk. Deciding on the timing of valvular intervention is therefore difficult in many patients, and contemporary clinical guidelines are often underpinned by historical observational data rather than high-quality randomised controlled trials. This article will review our current understanding of the pathophysiology of AS, describe and examine the evidence behind current guideline recommendations and explore potential future strategies to optimise the timing of valve intervention.

Pathophysiology of valvular stenosis and the hypertrophic response

Since the original description of AS by Mönckeberg in 1904, the decline in rheumatic fever and ageing population have led to a demographic transition towards fibrocalcific disease. For many years, fibrocalcific AS …

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