Do They Put A Camera In When U Have Aortic Stenoses Surgery
"If it ain't broke, don't fix it."
—Thomas Bertram Lance in Nation's Business organisation, May 1977
Aortic valve stenosis resulting from calcific thickening of a previously normal three-cusp aortic valve or a congenitally bicuspid aortic valve is a common clinical status in adult countries, and its prevalence is continuing to increase with crumbling of the population.1,2 In the Cardiovascular Health Study, which involved 5201 men and women >65 years of age, the prevalence of aortic stenosis was one.three% in subjects 65 to 75 years of age, 2.4% in subjects 75 to 85 years of age, and 4% in subjects >85 years of age.3 The precise mechanisms involved in the pathophysiology of aortic stenosis and its progression are incompletely understood, simply advancing age and atherosclerosis-related take a chance factors have been implicated in the process.four In fact, atherosclerotic coronary artery disease is present in nearly 50% of patients with aortic stenosis.5 Studies of valve pathology accept suggested a potential role for dyslipidemia, inflammation, and angiogenesis in the process, simply pharmacological therapies using statins to reduce dyslipidemia and associated inflammatory processes have yielded inconsistent but largely negative results in terms of reducing the rate of progression of aortic stenosis.6–10 Thus, in the absenteeism of specific and effective affliction-modifying medical therapies, surgical aortic valve replacement has been and continues to be the cornerstone of management of astringent aortic stenosis. There is general agreement amidst physicians and surgeons that when severe aortic stenosis is accompanied past 1 or more symptoms, such equally breast pain, syncope or near syncope, resuscitated sudden death, shortness of breath, fatigue, try intolerance, or left ventricular (LV) dysfunction, aortic valve replacement is recommended considering of well-established dismal consequence (≈50% bloodshed inside 3 years) in unoperated symptomatic cases and overall excellent surgical outcomes with relatively depression perioperative mortality and morbidity fifty-fifty among octogenariansxi–15 (Figures i and 2). Thus, despite the absence of data from a randomized clinical trial, symptomatic severe aortic stenosis is considered a course 1 indication for surgery past various professional person organizations.16,17 In some, specially elderly patients, timely surgical aortic valve replacement is not considered because symptoms are mistakenly attributed to comorbid conditions, or the severity of underlying aortic stenosis is underestimated by traditional indices such as aortic valve gradient and meridian velocity; this is specially the case in patients with low-flow, low-slope with depressed LV ejection fraction but is besides true with a recently recognized variant associated with paradoxical low-flow, low-slope severe aortic stenosis despite normal LV ejection fraction.18–20
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Figure i. The natural history of aortic stenosis, emphasizing a long presymptomatic period and the dismal event once symptoms begin. AV indicates boilerplate. Adapted from Ross and Braunwald.11
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Effigy two. The dramatically favorable upshot of symptomatic aortic stenosis patients undergoing surgical valve replacement is depicted. A, Comparing of percent survival in total male person population >40 years of age with that of adult patients with aortic stenosis with and without surgery. Adapted from Ross and Braunwald.11 B, Mean survival of patients with symptomatic aortic stenosis with and without surgery. Adapted from Schwarz et al.12
Response past Carabello on p 125
In the by few years, less invasive nonsurgical transcutaneous transfemoral (and to a lesser extent, transapical) techniques (such as transcatheter aortic valve implantation) for implanting a new bioprosthetic aortic valve inside a diseased severely stenotic native aortic valve have been developed and tested, with encouraging early on results in symptomatic patients considered nonsurgical candidates or at loftier surgical risk.21,22 Thus, in the absence of life-limiting frailty and comorbidity, surgical valve replacement, or in selected cases, nonsurgical transcutaneous bioprosthetic valve implantation, is recommended for symptomatic patients with severe aortic stenosis.
The Instance of Asymptomatic Severe Aortic Stenosis
Several observational studies have shown that a big number of patients with severe aortic stenosis deny symptoms for many years, consistent with the well-known presymptomatic phase that had originally been defined by Ross and Braunwald more than than twoscore years ago.11 Admittedly, a sure proportion of the so-called asymptomatic subjects may have subconsciously reduced their level of activity to low levels, thereby masking their truthful symptoms or effort intolerance, and their effort intolerance may be unmasked when considerately evaluated with a modified supervised stress test. Thus, physicians taking intendance of patients with aortic stenosis volition frequently face the dilemma of what to practise with a patient, especially an elderly patient (≥eighty years of age), with concrete and echocardiographic signs of severe aortic stenosis who claims to be asymptomatic. Because information technology is hard to make an asymptomatic subject feel better, preemptive surgery can only be justified when in that location is articulate testify that surgery actually improves long-term survival compared with watchful waiting and periodic reassessment. Unfortunately, the guidance on this dilemma is not informed by information from whatever randomized, controlled clinical trial, because no such trials have been conducted. So, what tin we glean from a large corporeality of nonrandomized observational information sets that tin can provide a reasoned framework for clinical determination making in asymptomatic patients with astringent aortic stenosis? The following questions may be posed:
| What is the natural history of severe asymptomatic aortic stenosis? | |||||
| What is the surgical outcome of patients with asymptomatic aortic stenosis? | |||||
| On the basis of the above, what should be done for the vast majority of patients with asymptomatic severe aortic stenosis? | |||||
| Are at that place subsets of patients with seemingly asymptomatic severe aortic stenosis who are at high risk for cardiovascular events? | |||||
| Does condom surgery improve the outcome of high-take chances cases of asymptomatic astringent aortic stenosis? | |||||
Natural History of Asymptomatic Astringent Aortic Stenosis and Results of Rubber Surgery
The 2 major concerns in patients with asymptomatic severe aortic stenosis are the risks of sudden death and the development of symptomatic or subclinical LV dysfunction. The overall incidence of sudden unexpected death in asymptomatic subjects with severe aortic stenosis is ≈0% to iv.1% per yr, with approximately an average ane% almanac run a risk.5,14,23 The overall take chances of sudden death in asymptomatic patients is comparable to or lower than that of surgical bloodshed. Even so, within the asymptomatic accomplice, progression of the disease and development of symptoms is quite common, with variable rates of symptom evolution depending on the initial severity of aortic stenosis (Tables one and 2).24–26
| Mild | Moderate | Severe | Very Severe | |
|---|---|---|---|---|
| Aortic valve area, cm2 | >1.5 cm | 1 to i.5 | <1 | <0.7 |
| Aortic valve area index, cm2/m2 | >0.nine | 0.vi–0.nine | <0.6 | <0.iv |
| Mean gradient, mm Hg | <25 | 25–40 | >40 | >l |
| Aortic jet velocity, g/due south | <three | iii–4 | >4 | >4.5 to 5 |
| Study and Twelvemonth | No. of Patients | Severity of Aortic Stenosis | Age, y | Hateful Follow-Up | Group | Event-Free Survival Without Symptoms |
|---|---|---|---|---|---|---|
| Kelly et al,24 1988 | 51 | Vmax >3.6 m/s | 63±8 | 5–25 mo | Overall | 59% at 15 mo |
| Pellikka et al,25 1990 | 113 | 5max ≥iv.0 1000/s | 40–94 | 20 mo | Overall | 86% at one y62% at 2 y |
| Kennedy et al,26 1991 | 66 | AVA 0.7–1.2 cm2 | 67±10 | 35 mo | Overall | 59% at four y |
| Otto et al,27 1997 | 123 | Vmax >2.six m/south | 63±16 | 2.5±1.4 y | Overall | 93±5% at 1 y62±8% at three y26±10% at 5 y |
| Subgroups:Vmax <3–4 m/s Vmax three–four m/s Vmax >three g/s | 84±16% at 2 y66±13% at 2 y21±18% at 2 y | |||||
| Rosenhek et al,282000 | 128 | Vmax >4.0 m/s | 60±xviii | 22±18 mo | Overall | 67±5% at ane y |
| 56±55% at two y | ||||||
| 33±v% at iv y | ||||||
| Subgroups: | ||||||
| No or mild Ca2+ | 75±9% at 4 y | |||||
| Moderate-severe Ca2+ | 20±5% at 4 y | |||||
| Amato et al,29 2001 | 66 | AVA ≤1.0 cm2 | 18–fourscore (50±15) | fifteen±12 mo | Overall | 57% at 1 y38% at ii y |
| Subgroups: | ||||||
| AVA ≥0.vii cmii | 72% at 2 y | |||||
| AVA <0.7 cmtwo | 21% at 2 y | |||||
| Negative do test | 85% at ii y | |||||
| Positive practise test | 19% at 2 y | |||||
| Das et al,30 2005 | 125 | AVA <i.4 cmii | 56–74 (mean 65) | 12 mo | Subgroups: | |
| AVA ≥1.2 cmii | 100% at one y | |||||
| AVA ≤0.8 cmii | 46% at i y | |||||
| No symptoms on practise test | 89% at 1 y | |||||
| Symptoms on do test | 49% at 1 y | |||||
| Pellikka et al,23 2005 | 622 | Vmax ≥4.0 m/s | 72±11 | v.4±4.0 y | Overall | 82% at one y67% at two y33% at 5 y |
Amongst patients <70 years of historic period, the overall surgical mortality associated with isolated aortic valve replacement is ≈1% to 3% (increasing to ≈5%–7% when associated coronary artery affliction requires additional intervention), and it is 5% to 15% among older adults, including octogenarians and some nonagenarians.31 In addition to death, stroke rates of ane.4% to four.8% have been reported subsequently aortic valve surgery.32,33 Thus, for the vast majority of asymptomatic patients with severe aortic stenosis, preemptive surgery would exist associated with a higher run a risk of overall death than the natural history of the status. In improver to surgical mortality, an aortic valve prosthesis, whether biological or mechanical, carries additional risks related to valve degeneration/failure, increased gamble of endocarditis, and complications resulting from antithrombotic therapy. Thus, for the vast majority of truly asymptomatic patients with severe aortic stenosis, watchful waiting and periodic reassessment would appear to be a reasonable arroyo. It is of import, still, to emphasize that when patients are followed upward in this way, cardiac surgery should be promptly undertaken when symptoms develop or evidence of LV dysfunction appears with a minimum of filibuster, because symptomatic patients do incur an increased risk of death (≈2% per calendar month). In the elderly patient with severe aortic stenosis, systemic hypertension and reduced aortic wall compliance are common comorbidities that can add together boosted afterload to the ventricle beyond that produced by valvular stenosis, and careful and judicious use of antihypertensive drug therapy to maintain optimal blood pressure control may exist helpful in preserving LV role.
Are At that place Subsets of Patients With Seemingly Asymptomatic Astringent Aortic Stenosis Who Are at High Risk for Cardiovascular Events?
As discussed above, a certain proportion of so-called asymptomatic subjects may accept subconsciously reduced their level of action to low levels, thereby masking their truthful exercise intolerance, and their exercise intolerance may be unmasked when evaluated objectively with a modified stress exam performed nether supervision (Tabular array 3).
| Abnormal resting ECG with LVH and a strain pattern |
| Doppler echocardiography variables |
| Very severe AS (jet velocity >iv.5 to 5.0 yard/s; AVA <0.half-dozen cm2) |
| Inappropriate LVH (≥15-mm wall thickness) |
| Reduced longitudinal strain |
| Reduced LVEF |
| Aberrant impedance |
| Abnormal exercise test |
| Induced symptoms |
| Serious arrhythmias |
| Ischemic response |
| Lack of increase in blood pressure (≥20 mm Hg) or drop in claret pressure |
| Abnormal biomarker |
| Elevated or rising BNP or NT-proBNP |
Function of Treadmill Exercise Testing
Until a few years ago, severe aortic stenosis was considered a contraindication for provocative testing because of the potential for precipitating severe complications. Several small studies over the past decade have examined the potential part of advisedly monitored treadmill exercise testing in predicting issue in seemingly asymptomatic patients with severe aortic stenosis.27,29,30,34–37 These studies have indicated that a carefully supervised modified Bruce protocol tin be safely practical to such patients and that induction of symptoms, ischemic manifestations, serious ventricular arrhythmias, or lack of expected rise in blood pressure and an actual hypotensive response predict an adverse upshot.27,29,30,34–37 These observational studies have shown that ≈xxx% of seemingly asymptomatic patients with severe aortic stenosis take an abnormal practice test,27 and in such patients, aortic valve replacement is considered reasonable; however, these data are derived from observational studies and not from any randomized clinical trials and hence are given only a course IIB recommendation past the American College of Cardiology/American Middle Association and European Guild of Cardiology guidelines.16,17
Electrocardiographic Criteria for LV Hypertrophy and Strain
Recently, investigators accept analyzed electrocardiographic data from 1533 asymptomatic aortic stenosis patients followed up for 4.3 years from the SEAS (Simvastatin and Ezetimibe in Aortic Stenosis) trial, in which patients with aortic stenosis were randomized to treatment with placebo or a combination of simvastatin and ezetimibe.38 Electrocardiographic criteria for LV hypertrophy and LV strain design were related to a poor prognosis in asymptomatic aortic stenosis patients independent of clinical and echocardiographic covariates, which confirms previously reported findings.39 These observations are intriguing and advise that patients with asymptomatic severe aortic stenosis with these electrocardiographic findings may merit closer and more frequent follow-upward.
Role of Biomarkers
Aortic stenosis increases myocardial diastolic and systolic wall stress, which induces the expression of N-concluding pro-brain natriuretic peptide and brain natriuretic peptide, and thus, increased levels of these biomarkers are plant in relationship to severity of aortic stenosis, with good correlation with the aortic valve area and severity of symptoms.xl–42 In several studies, patients with asymptomatic severe aortic stenosis and elevated natriuretic peptide levels (and those with increasing levels on serial follow-up) developed symptoms before and more frequently than patients with normal or lower natriuretic peptide levels40–42 (Tabular array 4). These findings suggest that patients with asymptomatic severe aortic stenosis with elevated or serially rising natriuretic peptide levels should exist monitored more closely for symptom development or deterioration of LV function, at which bespeak prompt surgical intervention may need to be considered.42 Nevertheless, the precise cut points at which intervention should be considered remain to be divers.
| Biomarker | 3 Months | 6 Months | 1 Year | P |
|---|---|---|---|---|
| BNP | <0.05 | |||
| <130 pg/mL | 100 | 90 | 66 | |
| >130 pg/mL | 94 | 64 | 34 | |
| NT-proBNP | <0.001 | |||
| <678 pg/mL | 100 | 88 | 69 | |
| >678 pg/mL | 92 | 58 | 18 |
Function of Doppler Echocardiography Predictors of Agin Outcome in Asymptomatic Subjects With Astringent Aortic Stenosis
Several observational studies have suggested that a number of parameters that tin exist obtained from 2-dimensional Doppler echocardiography studies during initial or sequential evaluation may portend a especially adverse prognosis fifty-fifty in asymptomatic subjects (Table 3). These parameters include evidence of very severe aortic stenosis, with an aortic valve surface area <0.6 cm/1000 2 ; loftier peak aortic jet velocity of >four.5 to five m/s43–45; rapid increase in gradient and velocity (>0.3 m/south per year); all-encompassing valvular calcification28; inappropriately increased LV mass46; abnormal valvuloarterial load/impedance, besides expressed as Zva (ratio of estimated LV pressure and stroke volume index)47,48; reduced LV ejection fraction (<l%); and reduced longitudinal LV strain despite normal LV ejection fraction.49 In particular, the presence of very astringent aortic stenosis with a peak aortic jet velocity exceeding 5 chiliad/s and especially exceeding 5.5 m/s (regardless of aortic valve expanse) in asymptomatic subjects has been associated with a particularly poor event-free survival, ranging from 49% to 81% at 1 yr, 32% to 48% at two years, 15% to 37% at 3 years, and seven% to 21% at 4 years.43 It has been suggested that the presence of any i or more of these variables should lead to serious consideration of preemptive surgery.
Should Rubber Surgery Be Considered for the Subset of Patients With Asymptomatic Severe Aortic Stenosis Who Have one or More Features of High Risk?
Equally of now, in that location are no randomized clinical trials addressing the issue of preemptive surgery in high-risk subsets of patients with asymptomatic severe aortic stenosis; even so, observational data provide some interesting insights. Kang et al44 reported the results of surgery versus no surgery in a nonrandomized cohort of 197 asymptomatic patients with very astringent aortic stenosis and normal LV ejection fraction (aortic valve area <0.75 cm 2 and peak aortic jet velocity >4.5 k/s), 102 of whom underwent preemptive surgery and 95 of whom were followed up without surgery. During an average follow-upwardly of ≈50 months, the operated group had no operative deaths, no cardiac deaths, and only 3 noncardiac deaths, whereas the conventionally treated group had 18 cardiac and 10 noncardiac deaths. The estimated actuarial half-dozen-twelvemonth cardiac and all-crusade mortality rates were 0% and 2% in the operated grouping versus 24% and 32%, respectively, in the conventionally managed grouping (P<0.001).44 From the total group, in 57 propensity score–matched pairs, all-cause mortality was significantly lower in the operated group than in the unoperated group, with a take chances ratio of 0.135 (P=0.008).44 It has been argued that asymptomatic patients with very severe aortic stenosis or those who exhibit 1 or more other features of high risk (Table 3) should be considered for preemptive surgery to avert the otherwise high bloodshed and morbidity.43–45,50 However, the show base for these recommendations is meager, with small numbers of patients and with a high likelihood of selection bias despite propensity matching, as well as the inclusion of patients who refused surgery when symptoms adult, which contributes to the loftier mortality in unoperated patients, and the frequent occurrence of noncardiac deaths in nonoperated patients that could not have been prevented by surgery anyhow.51 Thus, the recommendations for preemptive surgery are not entirely based on solid ground, and further evaluation, preferably with randomized trials, is needed to resolve this standing clinical conundrum. What is a clinician to do? In the absenteeism of clinical trial data, the clinician must monitor high-risk asymptomatic patients at closer intervals (perhaps every three months instead of every year as currently recommended by national guidelines) and arbitrate promptly, without delay, before long after the onset of symptoms or evidence of deterioration of LV part, to take hold of the patient earlier adverse events occur. A reasonable alternative to this approach might be to consider preemptive surgery for high-risk patients, provided that the expected institutional and surgeon-specific surgical mortality rates are depression and especially if delays in surgery later symptom onset are likely because of a waiting list.
Recently, Gada et al52 reported results from a conclusion-analytic model that accounted for non only bloodshed but also nonfatal agin effects from aortic valve surgery, equally well as costs associated with each surgery. The authors made certain assumptions to execute this model and compared immediate surgery to watchful waiting in asymptomatic astringent aortic stenosis patients.52 The authors concluded that watchful waiting was a meliorate strategy for most asymptomatic patients with severe aortic stenosis, and preemptive surgery was only a better strategy if the expected sudden death rate, in the absence of surgery, would be xiii% or higher. However, information technology is difficult to extrapolate from these model-derived data to the real-life scenario considering of various assumptions involved and the lack of accounting for various comorbidities that are common in elderly patients with severe aortic stenosis that tin can influence event.
Percutaneous Transfemoral Implantation of a Bioprosthetic Aortic Valve for Severe Aortic Stenosis: Will That Change the Prevailing Strategy?
Over the past several years, transfemoral transcutaneous aortic valve implants take been used in several thousand patients with severe aortic stenosis, and 2 randomized controlled trials have been completed.21,22 These studies included symptomatic patients with astringent aortic stenosis who were deemed either inoperable21 or high surgical risks,22 mostly because of comorbidity. Overall, curt-term and intermediate-term follow-up has provided gratifying results with this less invasive intervention, but vascular complication rates and stroke rates are significant enough to give ane pause. The short- and long-term risks and benefits of transcatheter aortic valve implantation in asymptomatic patients with severe aortic stenosis remain largely unknown. Therefore, at this fourth dimension, information technology does not announced that such a strategy volition be optimal for asymptomatic high-risk patients with aortic stenosis, but that could alter in the future with improvements in technology that could result in reduced rates of stroke and vascular complications. If and when that happens, the prevailing paradigm of watchful waiting may have to exist reconsidered.
Conclusions
For the vast bulk of asymptomatic patients with astringent aortic stenosis, watchful waiting appears to be the nigh reasonable strategy (Figure 3). These patients, peculiarly those with i or more than high-risk features, require close monitoring, with prompt surgical intervention immediately after symptom onset or with evidence of LV function deterioration. In selected cases and selected institutions where surgical bloodshed and morbidity are very low, high-chance patients may benefit from preemptive surgery, especially if delays in scheduling surgery are expected because of long waiting lists. Improvements in transcutaneous valve implant engineering science in the future, however, may modify the thresholds for preemptive intervention. In patients in whom symptomatic status is ambiguous, advisedly supervised treadmill testing might uncover serious symptoms justifying preemptive surgery, as currently recommended past guidelines. Nevertheless, for well-nigh asymptomatic patients, for now, "If information technology ain't broke, don't interruption it or gear up it" appears appropriate.
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Figure 3. A simplified algorithm for direction of patients with severe aortic stenosis. AVR indicates aortic valve replacement; CABG, coronary artery bypass grafting; LV, left ventricular; echo, echocardiography; Every bit, aortic stenosis; BNP, encephalon natriuretic peptide; NT-proBNP, N-last pro-BNP; LVH, left ventricular hypertrophy; and BP, claret force per unit area.
Acknowledgment
The secretarial assistance of Blessie Bulaon is gratefully acknowledged.
Disclosures
None.
Footnotes
References
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I read with pleasure the opinion offered by Dr Prediman Shah on the management of the patient with severe asymptomatic aortic stenosis. Our 2 treatises are far more notable for their similarities than their differences. Nosotros both annotation the relative lack of testify on which to base our conclusions. Unfortunately, it is highly unlikely that a large trial randomizing high-gamble asymptomatic patients to watchful waiting versus aortic valve replacement (AVR) will ever be performed, leaving the clinician to base management on the few data nosotros take. We both note very similar factors that put the asymptomatic patient at college risk, including an aberrant practise exam, a high transvalvular jet velocity, and elevated biomarkers. Nosotros diverge a bit on what to do with high-risk patients. Dr Shah advocates shut follow-up. I would contend that even follow-up at three-month intervals is inadequate, considering with a 2% adventure of sudden decease per month, once symptoms develop in that location could be a half dozen% bloodshed charge per unit for patients who developed symptoms shortly later an role visit and who waited 3 months to report the change. If the patient called his or her physician immediately on symptom onset, the issue would likely be practiced, but equally Dr Shah notes, there are no randomized information to evidence this arroyo. We also diverge on assessment of surgical run a risk. Dr Shah used reported serial to gauge run a risk, whereas I used the Society of Thoracic Surgeons' database, which generally projects lower surgical risk than do published series that clarify far fewer operations. What to do with asymptomatic patients with severe aortic stenosis boils down to analysis of risk. We can define patients for whom the risk of AVR is <1.0% and the hazard of waiting is far more than that. In my opinion, such patients will do good from early AVR.
Source: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.111.079368
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