Aortic stenosis: vigilant waiting only works for so long

The watchful wait only worked for about a year before patients with severe but asymptomatic aortic stenosis were at a disadvantage in terms of survival, researchers at one center found.

In a retrospective badysis of 265 asymptomatic patients, a difference in mortality occurred over time among the 39% recommended for aortic valve replacement (AVR) and other patients advised to wait:

• 1 year: 4.7% with AVR recommended against 5.2% waiting (not significant)
• 2 years: 7.5% vs 16.1% (P= 0.044)
• 3 years: 9.0% vs 21.1% (P= 0.011)

"Current data indicate that the prognosis for patients initially recommended WW [watchful waiting] for asymptomatic and severe AS [aortic stenosis] is poor, "according to S. Chris Malaisrie, MD, of Northwestern Memorial Hospital in Chicago, and his colleagues, in their online report in The annals of thoracic surgery.

"Previous studies have shown that asymptomatic AS management by waiting patient management can be a safe management strategy." Our study similarly suggests a period of "security" for WW, but only during the first year of management of it.The survival gap between WW and AVR 2 years is consistent with other studies suggesting a benefit for early AVR. "

After 5 years, 97 of the 104 people advised to obtain an AVR were finally operated on (a catheter replacement of the aortic valve) [TAVR] among these procedures), as well as 76 out of 161 of the closely supervised group (with four TAVRs).

AVR was an independent predictor of survival for both those advised to obtain it (HR 0.17, P= 0.038) and others advised to wait (HR 0.39, P= 0.044), compared to those who have never received it.

"Our data suggest that patients who ultimately had an AVR achieved a similar survival benefit regardless of the referral group (as long as they had an AVR)." Failure of the pregnant woman's management in the WW group may be entirely the result of failure to recognize the onset of symptoms and to deal with an AVR in a timely manner, "said the authors.

"Often, patients do not report typical symptoms (shortness of breath, chest pain, syncope and pre-syncope, etc.), but rather adapted their lifestyle to the increasing fatigue that they often attribute to aging", commented Mario Goessl. MD, PhD, of the Minneapolis Heart Institute, who did not participate in the study.

"With the excellent results of the two low-risk TAVR trials presented at the ACC 2019 conference last weekend (including asymptomatic patients in both cases), I personally believe that the replacement of the aortic valve, and in particular the TAVR, has become safe enough for early treatment of patients to take the plunge, "Goessl said MedPage today.

Aside from age-related problems, asymptomatic patients with a "relatively low risk" may generally be candidates for early surgical AVR, if not early VRE, said Michael Reardon, MD, of Houston Methodist.

The study could not determine the optimal age of intervention, acknowledged the Malaysian group. Another limitation was the imbalance between groups: the recommended cohort for an AVR was younger, its aortic valve areas were smaller, and its gradients were higher from the beginning.

Trials, including EARLY TAVR, are underway to more definitively determine the behavior of AVR in asymptomatic aortic stenoses.

2019-03-22T15: 30: 00-0400