Valve replacement surgery should be performed earlier than conventionally thought for people with aortic stenosis, as shown by new research published in the journal Open Heart.
Aortic stenosis is a common valvular disorder, especially in the elderly population, causing left ventricular outflow obstruction. Aetiologies include congenital (bicuspid/unicuspid), calcific, and rheumatic disease. Symptoms such as exertional dyspnoea or fatigue gradually develop after a long asymptomatic latent period of about 10 to 20 years. But many patients with aortic stenosis do not have symptoms even when they have severe narrowing of the valve and are thus not eligible for valve replacement.
The findings from this study show that these patients would benefit by undergoing a valve replacement – before they suffer irreversible heart muscle damage.
Lead researcher Prof Vassilios Vassiliou, from UEA’s Norwich Medical School, said: “The heart has four valves, which allow the blood to flow in one direction efficiently. With increasing age, one of the valves, the aortic valve, becomes increasingly narrowed or ‘stenosed’.
“A lot of patients with severe aortic stenosis do not have symptoms and therefore are not eligible for valve replacement according to the current guidelines.
“For these patients without symptoms, the guidelines suggest a ‘watchful waiting’ approach and intervention is recommended only when they show symptoms or develop pump failure.
“We wanted to know if it would be better to perform surgery and replace the valve sooner rather than later.”
In a systematic review, researchers compared early intervention versus conservative management in patients with asymptomatic severe aortic stenosis.
They then analysed data from all the available studies which involved a total of 3798 patients, out of which 302 were included in the two largest randomised controlled trials and 3496 in the observational studies.
Prof Vassiliou said: “We found that early intervention, before patients have symptoms, is associated with lower risk of death and hospitalisation for heart failure.
“By the time the patients develop symptoms, there has likely been irreversible damage to the muscle of the heart. This in turn may preclude a worse prognosis and adverse outcomes even after successful intervention.
“The timing of aortic valve intervention is crucial.
“We hope that our findings may herald the beginning of a change in the management of aortic stenosis patients, enabling the intervention to take place more commonly whilst the patients are asymptomatic.
“Ongoing trials investigating this high-risk population are anticipated to shed more light into the matter and in the identification of the optimal time of intervention,” he added.
Source: University of East Anglia
