Aortic valve replacement (AVR) is indicated for symptomatic aortic stenosis (AS), while close follow-up is recommended for asymptomatic patients, unless they have elevated aortic gradients, low ejection fraction, or abnormal stress tests. However, the optimal timing to perform AVR is uncertain, especially with recent evidence suggesting that patients with AS associated with signs of myocardial damage have higher long-term mortality and worse outcomes, even in the absence of symptoms.
Currently, the procedural risk and the recovery after transcatheter aortic valve replacement (TAVR) are more favorable compared with surgery. Similarly, more information is needed on this strategy in asymptomatic or minimally symptomatic patients with severe AS.
The aim of this retrospective study was to assess the outcomes of TAVR in minimally symptomatic patients with severe aortic stenosis.
The primary endpoint (PEP) was a composite of adverse events at 30 days (death, stroke, major bleeding, stage III acute kidney injury, need for dialysis, moderate to severe paravalvular leak).
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Among the 231,285 patients with AS treated with TAVR, 20% were minimally symptomatic. Their mean age was 80 years and 47.5% of them were women. The 1-year survival rate was higher for minimally symptomatic patients compared with those with moderate or severe symptoms (hazard ratio [HR] for death: 0.70 [95% confidence interval (CI): 0.66-0.75]). The results of the quality-of-life questionnaire increased by 2.7 points (95% CI: 2.6-2.9) at 30 days and 3.8 points (95% CI: 3.6-4.0) at 1 year in minimally symptomatic patients, compared with increases of 32.2 points (95% CI: 32.0-32.3) at 30 days and 34.9 points (95% CI: 34.7-35.0) at one year in patients with more acute symptoms. Minimally symptomatic patients were more likely to be alive at one year (odds ratio [OR]: 1.19 [95% CI: 1.16-1.23]).
Conclusion
This study showed that patients with minimally symptomatic AS experienced fewer procedural complications and better outcomes at 1 year after TAVR compared with patients with more acute symptoms. Randomized clinical trials are needed to confirm the safety and efficacy of TAVR in minimally symptomatic or asymptomatic patients with AS.
Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.
Original Title: Outcomes of Transcatheter Aortic Valve Replacement in Asymptomatic or Minimally Symptomatic Aortic Stenosis.
Reference: Chetan P. Huded, MD, MSC et al J Am Coll Cardiol Intv 2023.
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