Cardiologists make case against routine interventions for asymptomatic severe AS
The concept of treating asymptomatic severe aortic stenosis (AS) with early transcatheter aortic valve replacement (TAVR) or surgery has gained significant momentum, but many cardiologists are still unsure that this should be the recommended plan of action for every patient.
A new editorial in JAMA Cardiology, for example, explores the concerns of a trio of U.S. clinicians who think more long-term research is still required before any final conclusions can be reached.[1]
A bit of context about the rising momentum of early AVR
The early treatment of patients with asymptomatic severe AS has been a hot topic in recent months, especially after Généreux et al. presented initial findings from the EARLY TAVR trial at TCT 2024. In fact, an editorial in favor of early aortic valve replacement (AVR) was published in JAMA Cardiology back in February that made the case in favor of early AVR.
“We believe that the time has come to recommend AVR for asymptomatic patients with severe AS,” the authors wrote at the time. “This paradigm shift is anticipated to yield improved patient outcomes, public health, and resource utilization. It is time to act.”
The research teams behind meta-analyses recent published in the Journal of the American College of Cardiology and the American College of Cardiology reached similar conclusions.
Is it too early to know for sure?
To the cardiologists who wrote this latest editorial, it is simply still too early to tell if one option—early treatment or clinical surveillance—is going to consistently be better than the other when these patients present with evidence of asymptomatic AS.
“The question for the community is whether we should intervene in all patients with severe AS, irrespective of symptoms or the status of the left ventricle,” wrote first author Rick A. Nishimura, MD, a veteran Mayo Clinic cardiologist, and colleagues. “Before routinely offering valve intervention to the asymptomatic patient with severe AS, it is important to pause and critically examine the reports of improved outcomes with early operation vs a more conservative strategy. If a patient is asymptomatic, an early intervention will not make them feel better. There is no definitive evidence that early intervention will improve survival, except perhaps for patients at the highest risk with very severe AS.”
In addition, Nishimura et al. emphasized that sudden death, the “most featured outcome” associated with clinical surveillance, is quite rate among this patient population. TAVR and surgical aortic valve replacement (SAVR) procedures, meanwhile, always carry the risk of procedural mortality or morbidity.
“There are also the long-term consequences associated with a prosthetic valve, including infection, thrombosis, bleeding, and structural degeneration,” the editorial’s authors added.
Early aortic intervention likely ‘inevitable’ for many
Another key point of the editorial is that the authors agree that aortic valve replacement is “inevitable” for a majority patients who present with severe asymptomatic AS. However, they want clinicians to exercise considerable option, waiting three to five years in some cases where there are no clear benefits to immediate valve replacement.
“TAVR could be a reasonable approach in the recently retired 75-year-old individual with a mean aortic gradient of 65 mm Hg and an ejection fraction of 55%, who is a suitable candidate for a transfemoral approach,” they wrote. “Alternatively, a 50-year-old individual with a substantial home obligation to care for a loved one and a mean aortic gradient of 42 mm Hg might not want to take the time to recover from an operation and would be willing to continue with close follow-up.”
When a “wait and see” approach is chosen, the authors added, patients should be followed closely to ensure any signs of symptom progression are identified as quickly as possible.
Click here to read the full editorial.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.