Assessment of the Patient With Severe Aortic Stenosis
Getting Closer to the Truth
This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
It is better to be roughly right than precisely wrong.
—John Maynard Keynes
The optimal timing of aortic valve replacement (AVR) in the patient with severe aortic stenosis (AS) remains a commonly encountered clinical challenge in cardiovascular medicine. Practice guidelines give AVR a class I recommendation in patients with severe AS and symptoms of heart failure, angina, or syncope.1,2 However, watchful waiting for symptoms is associated with its own risks: sudden death is estimated to affect 1%/y of asymptomatic patients with isolated severe AS.3 Some patients will develop cardiac symptoms but not return for AVR, or symptoms may not be recognized as related to AS. Even the very presence of symptoms, especially in the elderly patient, may be difficult to ascertain.4
See Article by Bohbot et al
With these considerations, and in attempt to refine patient selection, the guidelines have added a few additional circumstances in which AVR is reasonable for the asymptomatic patient with severe AS. These include left ventricular dysfunction, defined as ejection fraction <50%, cardiac surgery for other indications, reduced exercise capacity or exertional hypotension demonstrated by exercise testing, or “very severe” AS.1,2 However, the US and European guidelines define very severe AS differently. The US guidelines specify that this applies to patients with peak aortic valve velocity (Vmax) ≥5.0 m/s, whereas the European guidelines define it as >5.5 m/s. The outcome study by Bohbot et al5 in this issue of Circulation: Cardiovascular Imaging sets out to determine the best threshold for defining very severe AS.
In this study …