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FIT Insights

An Uphill Gradient is No Longer an Uphill Battle:

Developments in Aortic Stenosis Management

As Dr. Eugene Braunwald provocatively stated in his article, “Aortic Stenosis: Then and Now” (Circulation, April 12, 2018), management of aortic stenosis has truly “entered the promise land.” In the last four decades, the diagnosis and management of aortic stenosis has changed dramatically. Aortic stenosis is recognized earlier in the disease process due to increased awareness and is treated either surgically or transcutaneously at earlier time points, resulting in prolonged freedom from morbidity and mortality.

In the early years of surgical open valvuloplasty, early mortality reached as high as 15% – much too high according to expected standards in today’s centers.1 This was largely due to inappropriate selection of patients with end-stage disease and irreversible myocardial damage. Dr. Braunwald himself discovered that, once symptoms of heart failure, syncope, and angina developed, death was imminent. As our tools for diagnosis, characterization and evaluation of severity of disease evolved with echocardiography and catheter-directed angiography and hemodynamics, surgeons and cardiologists worked together to balance the risk of surgical operation with mortality. Simultaneously, the nature of aortic stenosis was changing from that of largely rheumatic in origin to calcific degenerative disease in a much older population, raising the stakes of intervention.1

We now recognize that the population with aortic stenosis is more heterogenous, encompassing many subsets. Besides those with pure valve disease and preserved left ventricular function, other patients have severe aortic stenosis with low stroke volume index producing a low-flow low-gradient phenomenon that can occur with reduced (classical) or preserved (paradoxical) left ventricular function. To make matters worse, symptoms do not always correlate with disease severity. As a result, a clear path to intervention versus conservative management does not always exist. To aid in further characterizing severity and subset of aortic stenosis, dobutamine stress echocardiography and cardiac computed tomography are often performed.2

It is indisputable that patients with severe symptomatic aortic stenosis have a mortality upwards of 40% in two years if left alone.2 The controversy lies in the exact approach for intervention.

Surgical Aortic Valve Replacement (SAVR) offers a significant reduction in long-term mortality compared to medical therapy. However, it is associated with surprisingly high early mortality rates (8-33%).2

Transcutaneous Aortic Valve Replacement (TAVR) was initially approved for symptomatic severe aortic stenosis with a prohibitively high surgical risk. In the high surgical risk, low-flow severe aortic stenosis population, TAVR has gained much traction. This may be attributable to the benefits of a larger effective orifice area, no cardiopulmonary bypass time, shorter recovery time, and a minimally invasive approach. However, it does not come without complications, including paravalvular regurgitation, vascular complications, and relatively high incidence of pacemaker dependence. In the last decade, TAVR has really taken off and now is often the preferred approach in intermediate- and high-risk patients.2

Teasing out who might benefit from SAVR or TAVR has become quite an art. In the last few years, in many centers, TAVR is more commonly being performed compared to SAVR, though mostly in the population of octogenarians and older.3 The controversy exists today in how young and in how low risk a patient is TAVR still beneficial over SAVR. Questions to consider:

  • Will inserting transcutaneous valves into younger people lead to earlier degeneration and more valve in valve cases down the line?
  • Is TAVR really offering patients who are extremely high risk with multiple comorbidities improved quality and longevity of life?

These are the hard questions we now face as we enter a new decade of TAVR experience. Ongoing trials such as PARTNER-III and NOTION-2 will attempt to answer just some of these questions in the younger, low risk population. These advancements are certainly exciting, but we must keep our enthusiasm in proper perspective as the science further emerges and practice evolves. Meanwhile, we should apply central core ethical principles to maintain clinical equipoise as we continue our seemingly effortless climb to the top of the hill.

Author

Dipika Gopal, MD

Dr. Dipika Gopal, is a second-year cardiology fellow at the University of Pennsylvania in Philadelphia, with an interest in Preventive Cardiology and non-invasive imaging. She also has a passion for medical education and plans to pursue a career as a physician-educator.

Reference

  1. Braunwald E. Aortic Stenosis. 2018:2099-2101. doi:10.1056/NEJMoa1008232.2100.
  2. Saybolt MD, Fiorilli PN, Gertz ZM, Herrmann HC. Low-Flow Severe Aortic Stenosis: Evolving Role of Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv. 2017;10(8):1-10. doi:10.1161/CIRCINTERVENTIONS.117.004838.
  3. Thonghong T, De Backer O, Søndergaard L. Comprehensive update on the new indications for transcatheter aortic valve replacement in the latest 2017 European guidelines for the management of valvular heart disease. Open Hear. 2018;5(1):e000753. doi:10.1136/openhrt-2017-000753.