(Circulation. 1997;95:2241-2243.)
© 1997 American Heart Association, Inc.
Articles |
Timing of Valve Replacement in Aortic Stenosis
Moving Closer to Perfection
From the Cardiology Division, Department of Medicine, and the Gazes Cardiac Research Institute, Medical University of South Carolina, and the Ralph H. Johnson Department of Veterans Affairs, Charleston, SC.
Correspondence to Blase A. Carabello, MD, Charles Ezra Daniel Professor of Cardiology, Cardiology Division, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425-2221.
Key Words: • Editorials • valves • aorta • stenosis
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Introduction |
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The current results of aortic valve replacement for acquired aortic stenosis represent a medical triumph. Age-corrected survival after aortic valve replacement is excellent for patients over the age of 65 years and is similar to that of the normal population of that age.1 In the absence of extracardiac co-morbidity and in the absence of coronary artery disease, aortic valve replacement can be performed at a 2% to 3% operative mortality with an 85% age-corrected 10-year survival.1 This excellent outcome can be attributed to a variety of factors including the universal use of intraoperative cardiac protection, the insertion of hemodynamically excellent and durable valve prostheses, and the proper timing of aortic valve replacement.
Currently, timing in most cases is predicated upon the absence or
presence of symptoms. In the absence of cardiac symptoms, survival is
excellent without surgery.2 3 4 5 Since there is always some
risk of operative death and some risk of prosthetic
valve–related complications, the risk-benefit ratio does not favor
operating on the asymptomatic patient. However, studies
that have examined the "natural" history of aortic
stenosis in the modern era consistently report a few
subjects who progress from the asymptomatic state to the
development of symptoms and then to sudden death in a very short period
of time.3 4 In two echocardiographic
studies of asymptomatic patients in whom aortic
stenosis was quantified by Doppler interrogation as at
least moderate, 5 of 195 patients with aortic stenosis suffered
this rapid and unfortunate progression.3 4 Thus, the
guidelines for timing aortic valve replacement are not
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