ADVERTISEMENT
2.3 TAVR for Moderate AS: Not So Fast
These proceedings summarize the educational activity of the 17th Biennial Meeting of the International Andreas Gruentzig Society held January 30 to February 2, 2024 in Chiang Rai, Thailand.
Faculty Disclosures Vendor Acknowledgments
Statement of the problem or issue
Aortic valve stenosis (AS) has an unfavorable prognosis. Severe AS is associated with high mortality. Aortic valve replacement (AVR) can improve prognosis, but even with replacement, many patients are still faced with symptoms and early mortality from heart failure due in part to the adverse hemodynamic effects of chronically high afterload on the left ventricle. Figure 1 illustrates 4-year mortality rates with and without AVR for various degrees of AS severity.
While increased afterload from a stenotic valve contributes to cardiac damage, AS also is associated with concomitant conditions like hypertension, coronary artery disease, renal disease, and increasingly in the elderly population, frailty. Assessment of cardiac damage in AS, and methods to quantify it and better understand the implications for clinical outcomes, are now underway. A growing body of data support the hypothesis that cardiac damage affects prognosis after AVR. Figure 2 illustrates a staging system for cardiac damage, and its effects on mortality and poor quality of life (QoL) measures after AVR.
Gaps in current knowledge
It is clear that AS is both a valvular and a ventricular problem, and, therefore, AVR by either TAVR or SAVR often requires ongoing management of heart failure. This message is too often overlooked in patient education and shared decision making regarding an AVR procedure. The condition of the left ventricle prior to TAVR may be one of the key predictors of patient outcomes that could be modifiable.
An increasing focus on prevention and management may improve post-intervention health status and mortality. Earlier valvular intervention and use of guideline-directed medical therapy (GDMT) for both systolic and diastolic heart failure could be impactful. Specifically, the role of SGLT2 inhibition and use of ARNIs in moderate and severe AS are areas of focus currently.
Importantly, consideration of lifetime management of patients with AS is needed when considering earlier intervention. Patient goals and preferences may differ from that of the clinical team, and best practices for incorporating patient values into cardiovascular decision-making processes continues to be a focus of ongoing research.
Possible solutions and future directions
Ongoing randomized trials are evaluating the effect of earlier treatment of AS when moderate stenosis is identified, in conjunction with medical therapy, on quality of life and clinical outcomes like heart failure events and mortality. These trials are designed to answer the following questions:
-
- How strong is the evidence that earlier AVR will improve ventricular function?
- How are harms balanced with benefits when considering earlier AVR? (valve degeneration over time, pacemaker, coronary re-access)
- How necessary is GDMT with SGTL2inh in moderate AS trials?
- What are strengths and weaknesses of the “HF event” endpoint?
- What will be the role for device-first strategies in structural heart interventions with heart failure as a primary endpoint?
- How best to integrate patient goals and preferences in trial cycle and clinical decision making?
References
- Généreux P, Sharma RP, Cubeddu RJ, et al. The mortality burden of untreated aortic stenosis. J Am Coll Cardiol. 2023;82(22):2101-2109. doi: 10.1016/j.jacc.2023.09.796 PMID: 37877909
- Généreux P, Cohen DJ, Pibarot P, et al. Cardiac damage and quality of life after aortic valve replacement in the PARTNER trials. J Am Coll Cardiol. 2023;81(8):743-752. doi: 10.1016/j.jacc.2022.11.059 PMID: 36813373
- Col NF, Otero D, Lindman BR, Horne A, Levack MM, Ngo L, Goodloe K, Strong S, Kaplan E, Beaudry M, Coylewright M. What matters most to patients with severe aortic stenosis? PLoS One. 2022;17(8):e0270209 PMID: 35951553
© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.
