Author + information
- Received August 17, 2018
- Revision received October 17, 2018
- Accepted October 18, 2018
- Published online January 7, 2019.
- Philippe Pibarot, DVM, PhDa,∗ (, )
- David Messika-Zeitoun, MDb,
- Ori Ben-Yehuda, MDc,d,
- Rebecca T. Hahn, MDc,d,
- Ian G. Burwash, MDb,
- Nicolas M. Van Mieghem, MD, PhDe,
- Ernest Spitzer, MDe,f,
- Martin B. Leon, MDc,
- Jeroen Bax, MDg and
- Catherine M. Otto, MDh
- aInstitut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Université Laval, Québec, Canada
- bUniversity of Ottawa Heart Institute, Ottawa, Ontario, Canada
- cColumbia University Medical Center/New York-Presbyterian Hospital, New York, New York
- dCardiovascular Research Foundation, New York, New York
- eDepartment of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
- fCardialysis, Rotterdam, the Netherlands
- gDepartment of Cardiology Leiden University Medical Centre, Leiden, the Netherlands
- hDivision of Cardiology, University of Washington School of Medicine, Seattle, Washington
- ↵∗Address for correspondence:
Dr. Philippe Pibarot, Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada.
Clinical management of patients with only moderate aortic stenosis (AS) but symptoms of heart failure with a reduced left ventricular ejection fraction (HFrEF) is challenging. Current guidelines recommend clinical surveillance with multimodality imaging; aortic valve replacement (AVR) is deferred until the stenosis becomes severe. Given the known benefits of afterload reduction in management of patients with HFrEF, it has been hypothesized that AVR may be beneficial in patients with only moderate AS who present with HFrEF. In this article, we first review the current approach for management of patients with moderate AS and HFrEF based on close clinical and imaging surveillance with AVR delayed until AS is severe. We then discuss the case for transcatheter AVR (TAVR) earlier in the disease course, when AS is moderate, based on stress echocardiographic data. We conclude with a detailed summary of the TAVR UNLOAD (Transcatheter Aortic Valve Replacement to UNload the Left Ventricle in Patients With ADvanced Heart Failure) trial, in which patients with moderate AS and HFrEF are randomized to guideline-directed heart failure therapy alone versus guideline-directed heart failure therapy plus TAVR.
- aortic stenosis
- computed tomography
- dobutamine stress echocardiography
- systolic heart failure
- transcatheter aortic valve replacement
Dr. Pibarot has received funding from Edwards Lifesciences and Medtronic for echocardiography core laboratory analyses in transcatheter heart valves with no personal compensation. Dr. Hahn has received funding from Edwards Lifesciences for echocardiography core laboratory analyses with no personal compensation. Dr. Spitzer has received speaker fees from Edwards Lifesciences. Dr. Messika-Zeitoun is a consultant for Edwards Lifesciences, Mardil, Abbott, and Cardiawave. Dr. Van Mieghem has received research grants from Medtronic, Abbott, Boston Scientific, and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 17, 2018.
- Revision received October 17, 2018.
- Accepted October 18, 2018.
- 2019 American College of Cardiology Foundation
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