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STATE-OF-THE-ART PAPER

Management of Asymptomatic Severe Aortic Stenosis

Jacob P. Dal-Bianco, MD^_*, Bjoy K. Khandheria, MBBS, FACC, FASE, FESC, Farouk Mookadam, MD, FRCP, MSc, Federico Gentile, MD and Partho P. Sengupta, MBBS, MD, DM^,_*

^_* Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona

Manuscript received May 5, 2008; revised manuscript received June 30, 2008, accepted July 1, 2008.

^_* Reprint requests and correspondence: Dr. Partho P. Sengupta, Division of Cardiovascular Diseases, Mayo Clinic Arizona, 13400 East Shea Boulevard, Scottsdale, Arizona 85259 (Email: sengupta.partho{at}mayo.edu).

Patients with symptomatic severe aortic stenosis (AS) benefit from aortic valve replacement (AVR). Management of severe AS in the absence of symptoms is, however, controversial and often challenging. Unselected premature AVR carries the risks of cardiac surgery; delayed AVR due to unrecognized symptoms can result in a dismal outcome. Echocardiography is the standard tool to evaluate and follow patients with AS. Nevertheless, most of the current echocardiographic parameters have limitations in predicting symptom onset and clinical outcome. The same applies to clinical parameters, exercise stress testing, and other imaging modalities used in AS evaluation and serial follow-up. Predictors of outcome could, however, help to identify asymptomatic patients who would benefit from expedited AVR with the goal to reduce mortality. This review will discuss the most relevant clinical studies and guidelines on management of asymptomatic severe AS, with an emphasis on providing concise information for identifying patients at high risk.

Key Words: aortic stenosis • asymptomatic • management • outcome • predictor • severe

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   AS = aortic stenosis   AVA = aortic valve area   AVR = aortic valve replacement   BAV = bicuspid aortic valve   BNP = brain natriuretic peptide   CI = confidence interval   CR = contractile reserve   ESC = European Society of Cardiology   HR = hazard ratio   LV = left ventricle/ventricular   LVEF = left ventricular ejection fraction   OR = odds ratio   RR = relative risk

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