What are the causes of Aortic Valve Replacement (AVR) positivity?

From the Guidelines

Aortic Valve Replacement (AVR) is typically considered in patients with severe aortic stenosis (AS) who are symptomatic or have specific high-risk features.

Causes of AVR Positivity

The following are the main causes of AVR positivity:

• Symptomatic severe AS: Patients with severe AS who experience symptoms such as exertional dyspnea, angina, or syncope are likely to benefit from AVR 1.
• Asymptomatic severe AS with high-risk features: Asymptomatic patients with severe AS and high-risk features such as very severe AS (aortic velocity ≥5.0 m/s or mean pressure gradient ≥60 mm Hg), low surgical risk, and abnormal exercise test results may also benefit from AVR 1.
• Asymptomatic severe AS with systolic LV dysfunction: Asymptomatic patients with severe AS and systolic left ventricular (LV) dysfunction (LVEF <50%) not due to another cause may benefit from AVR 1.
• Asymptomatic severe AS with abnormal exercise test: Asymptomatic patients with severe AS and abnormal exercise test results, such as symptoms on exercise or a fall in blood pressure below baseline, may benefit from AVR 1.
• Severe AS with low-flow, low-gradient: Patients with severe AS and low-flow, low-gradient (mean pressure gradient <40 mmHg) may benefit from AVR, especially if they have symptoms or evidence of flow reserve 1.

Key Factors Influencing AVR Decision

The decision to perform AVR is influenced by several factors, including:

• Severity of AS: The severity of AS, as measured by aortic velocity or mean pressure gradient, is a key factor in determining the need for AVR 1.
• Symptom status: The presence or absence of symptoms, such as exertional dyspnea, angina, or syncope, is an important factor in determining the need for AVR 1.
• LV function: The presence of systolic LV dysfunction (LVEF <50%) not due to another cause is a key factor in determining the need for AVR in asymptomatic patients 1.
• Surgical risk: The surgical risk, including the risk of complications and mortality, is an important factor in determining the need for AVR 1.
• Patient preferences: Patient preferences and values, including the desire to avoid surgery or to improve quality of life, are also important factors in determining the need for AVR 1.

From the Research

Causes of Aortic Valve Replacement (AVR) Positivity

The causes of AVR positivity can be attributed to several factors, including:

• Cardiovascular mortality: Studies have shown that patients who underwent AVR had a higher risk of cardiovascular death compared to the general population 2.
• Asymptomatic severe aortic stenosis: AVR in asymptomatic patients with severe aortic stenosis and preserved left ventricular function has been associated with significant survival benefits 3.
• High-risk patients: Rapid-deployment AVR has been shown to be a reliable and effective alternative to conventional AVR in high-risk patients, providing better outcomes and lower mortality rates 4.
• Moderate mixed aortic valve disease: AVR has been associated with positive clinical results in patients with moderate mixed aortic valve disease, reducing the risk of all-cause death and heart failure hospitalization 5.

Patient Selection and Special Considerations

Patient selection and special considerations play a crucial role in determining the success of AVR, including:

• Technical and anatomical considerations: The use of sutureless or rapid deployment valves requires careful patient selection and technical considerations to minimize complications and optimize outcomes 6.
• Complex procedures: Rapid-deployment AVR may be beneficial in complex procedures, such as minimally invasive AVR or small aortic annulus, but requires careful patient selection and technical expertise 6.
• Long-term outcomes: Further studies are needed to accumulate long-term outcomes and clarify the advantages of sutureless or rapid deployment valves in terms of mortality 6.