Author + information
- Received November 20, 2018
- Revision received January 2, 2019
- Accepted January 22, 2019
- Published online June 12, 2019.
- Brian R. Lindman, MDa,
- Marc R. Dweck, MDb,
- Patrizio Lancellotti, MDc,
- Philippe Généreux, MDd,e,
- Luc A. Piérard, MDc,
- Patrick T. O’Gara, MDf,∗∗ ( and )
- Robert O. Bonow, MD, MSg,∗ ()
- aVanderbilt University Medical Center, Nashville, TennesseeVanderbilt University Medical Center, Nashville, Tennessee
- bCardiovascular Science, University of Edinburgh, Edinburgh, United KingdomCardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- cCardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University of Liège Hospital, Centre Hospitalier Universitaire du Sart Tilman, Liège, BelgiumCardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University of Liege Hospital, Centre Hospitalier Universitaire du Sart Tilman, Liege, Belgium
- dClinical Trials Center, Cardiovascular Research Foundation, New York, New YorkClinical Trials Center, Cardiovascular Research Foundation, New York, New York
- eGagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New JerseyGagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
- fCardiovascular Division, Brigham and Women’s Hospital, Boston, MassachusettsCardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
- gDepartment of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IllinoisDepartment of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
• Although AS is the most common heart valve lesion encountered in clinical practice, affecting 2% to 5% of older adults, determining its severity in asymptomatic patients remains problematic.
• New methods of risk stratification for asymptomatic patients with AS are emerging, including circulating biomarkers, Doppler-derived global longitudinal strain, and magnetic resonance assessment of left ventricular myocardial fibrosis.
• Prospective randomized trials are underway for asymptomatic patients with AS to assess timing of aortic valve replacement and determinants of clinical outcomes.
New insights into the pathophysiology and natural history of patients with aortic stenosis, coupled with advances in diagnostic imaging and the dramatic evolution of transcatheter aortic valve replacement, are fueling intense interest in the management of asymptomatic patients with severe aortic stenosis. An intervention that is less invasive than surgery could conceivably justify pre-emptive transcatheter aortic valve replacement in subsets of patients, rather than waiting for the emergence of early symptoms to trigger valve intervention. Clinical experience has shown that symptoms can be challenging to ascertain in many sedentary, deconditioned, and/or elderly patients. Evolving data based on imaging and biomarker evidence of adverse ventricular remodeling, hypertrophy, inflammation, or fibrosis may radically transform existing clinical decision paradigms. Clinical trials currently enrolling asymptomatic patients have the potential to change practice patterns and lower the threshold for intervention.
Dr. Lindman is a consultant for Medtronic; has received investigator-initiated research grants from Edwards Lifesciences; and has received investigator-initiated research grants and honorarium for scientific advisory board from Roche. Dr. Généreux has received consultant and speaker fees from Abbott Vascular, Cardinal Health, Edwards Lifesciences, and Medtronic; and has served as a consultant for Boston Scientific and as a principal investigator for the EARLY TAVR trial. Dr. Dweck has received the Sir Jules Thorn Award for Biomedical Research; and has served as a principal investigator for the EVOLVED trial. Dr. O’Gara has served as a consultant for Medtronic (for the Apollo trial) and Edwards Lifesciences (for the EARLY TAVR trial). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 20, 2018.
- Revision received January 2, 2019.
- Accepted January 22, 2019.
- 2019 American College of Cardiology Foundation
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