The Natural History and Rate of Progression of Aortic Stenosis
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Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients. An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords “Aortic stenosis”, “SAVR”, “TAVR”, and “Asymptomatic”. A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.
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Coronary bypass surgery (CBS) is performed in many older patients who frequently also have mild calcific aortic stenosis. It is important that a correct assessment of the severity of aortic stenosis is done by calculating the aortic valve area. Mild aortic stenosis is aortic valve area >1.5 cm(2), >0.9 cm(2)/m(2); severe aortic stenosis is aortic valve area < or =1.0 cm(2), < or =0.6 cm(2)/m(2). Patients who have severe aortic stenosis should have aortic valve replacement (AVR) at the time of CBS. Patients with mild aortic stenosis should not have AVR simultaneously with CBS because: 1) patients having AVR+CBS have a higher operative and 10-year mortality; 2) prosthetic heart valves are associated with a complication rate of 2%-6% per year; and 3) only about 12% of patients with mild aortic stenosis will have developed severe aortic stenosis in 10 years. Performing AVR for mild aortic stenosis at the time of CBS will probably result in 91 unnecessary AVRs and 29 excess deaths in 10 years.
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Aims To determine whether low-flow/low-gradient (LF/LG) aortic stenosis affects survival after transcatheter aortic valve implantation (TAVI), we performed a meta-analysis of currently available studies. Methods MEDLINE and EMBASE were searched through January 2019 using PubMed and OVID. Observational studies comparing all-cause mortality after TAVI for patients with classical LF/LG (C/LF/LG) aortic stenosis versus normal-flow/high-gradient (NF/HG) aortic stenosis, paradoxical LF/LG (P/LF/LG) aortic stenosis versus NF/HG aortic stenosis, and (3) C/LF/LG aortic stenosis versus P/LF/LG aortic stenosis were included. Study-specific estimates, risk and hazard ratios of mortality, were combined in the random-effects model. Results Our search identified nine eligible studies including a total of 5512 TAVI patients. Pooled analysis demonstrated significantly higher early mortality in C/LF/LG aortic stenosis than NF/HG aortic stenosis (risk ratio, 1.72; P = 0.02) and no statistically significant difference in early mortality between P/LF/LG aortic stenosis and NF/HG aortic stenosis ( P = 0.67) and between C/LF/LG aortic stenosis and P/LF/LG aortic stenosis ( P = 0.51). Midterm mortality in C/LF/LG (risk ratio/hazard ratio, 1.73; P = 0.0003) and P/LF/LG aortic stenosis (risk ratio/hazard ratio, 1.48; P < 0.0001) was significantly higher than that in NF/HG aortic stenosis. There was no statistically significant difference in midterm mortality between C/LF/LG aortic stenosis and P/LF/LG aortic stenosis ( P = 0.63). Conclusion After TAVI, C/LF/LG aortic stenosis is associated with increased early mortality compared with NF/HG, and C/LF/LG and P/LF/LG aortic stenosis is associated with increased midterm mortality compared with NF/HG aortic stenosis despite no difference in early mortality between P/LF/LG aortic stenosis and NF/HG aortic stenosis. There is no difference in early and midterm mortality between C/LF/LG aortic stenosis and P/LF/LG aortic stenosis.
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