Debate. Asymptomatic severe aortic stenosis: when should we intervene? The interventional cardiologist’s perspective

Abstract

QUESTION: What relevant evidence could support aortic valve replacement today in cases of true severe asymptomatic aortic stenosis? Are there any studies on both techniques, surgery and transcatheter implantation? ANSWER: Ross and Braunwald’s1 description of the outcomes of patients with severe symptomatic aortic stenosis (AS) almost 60 years ago laid the foundations for the indication for surgery—the first-line therapy to date—to treat this disease, although transcatheter aortic valve implantation (TAVI) is also indicated. At a time when surgery was the only therapeutic option available, with mortality rates close to 3% to 4%, nobody thought of treating asymptomatic patients, who had a risk of sudden death of nearly 1%. These findings were confirmed by later studies, and the treatment of asymptomatic AS continued to lack evidence until the first decade of the 21st century when observational studies with small series of patients with severe asymptomatic AS (Vmax ≥ 4 m/s and mean gradient ≥ 40 mmHg) began to be published. In all of them, the results favored early surgical treatment. In the study of 197 patients by Kang et al.,2 the primary endpoint was a composite of operative and follow-up mortality. The 6-year cardiac and all-cause mortality rates were 0% and 2...