From the Guidelines
Intervention in severe Aortic Stenosis (AS) is indicated in symptomatic patients, as well as in asymptomatic patients with severe AS and systolic left ventricular dysfunction (LVEF <50%) not due to another cause, or those with abnormal exercise test showing symptoms clearly related to AS, according to the European Society of Cardiology (ESC) guidelines. The indications for intervention in severe AS are based on the latest guidelines, which prioritize the prevention of irreversible cardiac damage, sudden cardiac death, and improvement of long-term survival and quality of life 1.
Key Indications for Intervention
- Symptomatic patients with severe AS should undergo intervention regardless of left ventricular ejection fraction (LVEF) 1
- Asymptomatic patients with severe AS and systolic left ventricular dysfunction (LVEF <50%) not due to another cause 1
- Asymptomatic patients with severe AS and abnormal exercise test showing symptoms clearly related to AS 1
- Patients with very severe AS (peak velocity >5.5 m/s) or severe valve calcification with rapid progression (≥0.3 m/s/year) 1
- Patients with markedly elevated BNP levels (>3x age/sex-corrected normal range), severe pulmonary hypertension (systolic pulmonary artery pressure >60 mmHg), or extremely severe AS (peak velocity >5.0 m/s) combined with low surgical risk 1
Rationale for Recommendations
The rationale for these recommendations is that severe AS is a progressive disease with poor outcomes if left untreated once symptoms develop or when there is evidence of myocardial damage 1. Early intervention in appropriate candidates can prevent irreversible cardiac damage, sudden cardiac death, and improve long-term survival and quality of life. The ESC guidelines emphasize the importance of individualized treatment decisions, taking into account patient preferences, values, and risk profiles 1.
Choice of Intervention
The choice of intervention, either surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI), depends on multiple factors, including surgical risk, patient frailty, comorbid conditions, and patient preferences and values 1. The Heart Team should make the decision based on a comprehensive evaluation of the patient's condition and the available evidence 1.
From the Research
Indications for Intervention in Severe Aortic Stenosis (AS)
The European Society of Cardiology (ESC) guidelines recommend intervention in severe AS under certain conditions. The indications for intervention include:
- Symptomatic severe AS 2, 3
- Asymptomatic severe AS with left ventricular dysfunction, defined as a left ventricular ejection fraction (LVEF) ≤35% 4 or <50% 5
- Asymptomatic severe AS with an abnormal exercise test, a high likelihood of rapid progression, or very severe AS in the presence of low surgical risk 3
- Asymptomatic patients with severe AS and a high risk of death while waiting for intervention, such as those with severe left ventricular dysfunction 4
Timing of Intervention
The optimal timing of intervention in asymptomatic severe AS remains controversial. However, earlier intervention may be indicated in certain scenarios, such as:
- Asymptomatic patients with severe AS and subclinical left ventricular dysfunction, as detected by global longitudinal strain (GLS) 5
- Asymptomatic patients with severe AS and a high risk of rapid progression or adverse cardiovascular events 2, 6
- Patients with high-gradient severe AS and severe left ventricular dysfunction, who have a higher risk of death while waiting for intervention 4