Timing of surgery for asymptomatic patients with severe aortic valve stenosis: An updated systematic review and meta-analysis

Early Aortic-Valve Replacement in Patients With Asymptomatic Severe Aortic Stenosis With Preserved Left Ventricular Systolic Function: A Systematic Review and Meta-Analysis

Current guidelines recommend routine clinical surveillance for patients with asymptomatic severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF). However, the role of early aortic valve replacement (AVR) as compared with conservative treatment in these patients remains unclear. We systematically searched PubMed, Embase and Cochrane databases to identify studies comparing early AVR versus conservative treatment in asymptomatic patients with severe AS and preserved LVEF. All statistical analyses were performed using R software version 4.3.1 with a random-effects model. Seven studies comprising 2,531 patients with asymptomatic severe AS and preserved LVEF were included, of whom 1,234 (49%) underwent AVR. Median follow-up time was 49.3 months. Early AVR was associated with significantly lower incidence of all-cause (HR 0.51; 95% CI 0.31 to 0.83) and cardiac mortality (RR 0.51; 95% CI 0.30 to 0.89). There were no significant differences between early AVR and conservative treatment in terms of sudden death, hospitalization for cardiovascular (CV) causes, stroke, or myocardial infarction (MI). However, upon a subanalysis of randomized controlled trials (RCTs) only, patients undergoing early AVR had lower rates of hospitalization for CV causes (RR 0.41; 95% CI 0.27 to 0.63) and stroke (RR 0.62; 95% CI 0.40 to 0.95), with no difference in terms of all-cause mortality, sudden death, MI, or cardiac death. In this meta-analysis, early AVR was associated with reduced rates of all-cause and cardiac mortality, while yielding similar rates of stroke, hospitalization for CV causes, MI, or sudden death in the overall cohort analysis as compared with conservative treatment.

Systematic review and meta-analysis of early aortic valve replacement versus conservative therapy in patients with asymptomatic aortic valve stenosis with preserved left ventricle systolic function

BACKGROUND

A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function.

METHODS AND RESULTS

We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I2=31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I2=84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding.

CONCLUSION

We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations.

PROSPERO REGISTRATION NUMBER

CRD42022306132.

Advantages of Multiposition Scanning in Echocardiographic Assessment of the Severity of Discordant Aortic Stenosis

AIM OF THE STUDY

The aim of this study was to perform a comparative analysis of severity of discordant aortic stenosis (AS) assessment using multiposition scanning and the standard apical window.

MATERIALS AND METHODS

All patients (n = 104) underwent preoperative transthoracic echocardiography (TTE) and were ranked according to the degree of AS severity. The reproducibility feasibility of the right parasternal window (RPW) was 75.0% (n = 78). The mean age of the patients was 64 years, and 40 (51.3%) were female. In 25 cases, low gradients were identified from the apical window not corresponding to the visual structural changes in the aortic valve, or disagreement between the velocity and calculated parameters was detected. Patients were divided into two groups: concordant AS (n = 56; 71.8%) and discordant AS (n = 22; 28.2%). Three individuals were excluded from the discordant AS group due to the presence of moderate stenosis.

RESULTS

Based on the comparative analysis of transvalvular flow velocities obtained from multiposition scanning, the concordance group showed agreement between the velocity and calculated parameters. We observed an increase in the mean transvalvular pressure gradient (ΔPmean) and peak aortic jet velocity (Vmax), ΔPmean in 95.5% of patients, velocity time integral of transvalvular flow (VTI AV) in 90.9% of patients, and a decrease in aortic valve area (AVA) and indexed AVA in 90.9% of patients after applying RPW in all patients with discordant AS. The use of RPW allowed the reclassification of AS severity from discordant to concordant high-gradient AS in 88% of low-gradient AS cases.

CONCLUSION

Underestimation of flow velocity and overestimation of AVA using the apical window may lead to misclassification of AS. The use of RPW helps to match the degree of AS severity with the velocity characteristics and reduce the number of low-gradient AS cases.

Asymptomatic Severe Aortic Stenosis: Contemporary Evaluation and Management

Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries and most prevalent in the elderly. According to the current guidelines, intervention is recommended in symptomatic severe AS; however, in asymptomatic patients, aortic valve replacement (AVR) is considered when symptoms appear or the left ventricular dysfunction occurs, but the evidence supports these indications are poor. The optimal timing and modality of intervention in asymptomatic severe AS (ASAS) remain controversial. Earlier AVR in certain scenarios has been increasingly supported by some groups before subclinical irreversible myocardial damage occurs. In addition, the continuous advancement of percutaneous and surgical approaches where associated with a substantial decrease in mortality and perioperative complications which made many authors advocate for early intervention in those patients. Our review highlights the contemporary evaluation and management of ASAS and summarizes the current scientific evidence regarding optimal timing for intervention and indications for early AVR in such patients.