We searched PubMed, MEDLINE, the Cochrane Library, and Embase for full-text reports published from Jan 1, 2000, to Feb 15, 2016. The search terms “aortic valve”, “aortic stenosis”, and “aortic regurgitation” were combined with many search terms for pathophysiology, epidemiology, natural history, diagnosis, management, and valve replacement. We largely selected publications from the past 5 years, but did not exclude commonly referenced and highly regarded older publications. We also searched the
SeriesManagement strategies and future challenges for aortic valve disease
Introduction
After decades of relative quiescence, the management of patients with aortic valve disease is again garnering interest due to the convergence of several factors. Disease prevalence is increasing as the global population ages.1, 2 Many patients with severe symptomatic aortic stenosis remain untreated3, 4 and many with aortic regurgitation develop left ventricular dysfunction before the onset of symptoms.5 Finally, the emergence of less-invasive transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) for patients with aortic stenosis has created new opportunities for treatment, although also raising several challenges.6, 7, 8, 9 In this paper in The Lancet Series on valvular heart disease, we highlight important changes in the management of patients with aortic valve disease and focus a prescient lens on future expectations.
Section snippets
Pathophysiology
The symptom triad of angina, syncope, and dyspnoea represents a late-stage consequence of chronic progressive left ventricular overload caused by worsening aortic stenosis, which usually has developed over several decades.10 Compensatory changes to maintain cardiac output, including increases in left ventricular wall thickness and contractility, are ultimately overwhelmed, resulting in the typical pathobiology of severely decreased diastolic compliance, subendocardial ischaemia, exhausted
Background
Aortic regurgitation is much less prevalent than aortic stenosis and represents a lesser public health concern. Patients generally present at younger ages than those with aortic stenosis. Aortic regurgitation is mainly related to congenital bicuspid valve disease or primary disease of the aortic root or ascending aorta, although degenerative changes of trileafet valves develop with increasing age. The diastolic murmur is often difficult to discern and, therefore, the flow-related systolic
Conclusions
The assessment and management of patients with aortic valve disease are rapidly changing with new insights into the natural history of the disease, advances in imaging capabilities, and evolving minimally invasive surgical and transcatheter solutions for valve replacement. In aortic stenosis, TAVR is expanding to address the needs of lower-risk and higher-risk patients, with new indications for valve-in-valve treatment in patients with failing bioprosthetic valves. Broadening of the indications
Search strategy and selection criteria
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