Elsevier

The Lancet

Volume 387, Issue 10025, 26 March–1 April 2016, Pages 1312-1323
The Lancet

Series
Management strategies and future challenges for aortic valve disease

https://doi.org/10.1016/S0140-6736(16)00586-9Get rights and content

Summary

The management of aortic valve disease has been improved by accurate diagnosis and assessment of severity by echocardiography and advanced imaging techniques, efforts to elicit symptoms or objective markers of disease severity and progression, and consideration of optimum timing of aortic valve replacement, even in elderly patients. Prevalence of calcific aortic stenosis is growing in ageing populations. Conventional surgery remains the most appropriate option for most patients who require aortic valve replacement, but the transcatheter approach is established for high-risk patients or poor candidates for surgery. The rapid growth of transcatheter aortic valve replacement has been fuelled by improved technology, evidence-based clinical research, and setting up of multidisciplinary heart teams. Aortic regurgitation can be difficult to diagnose and quantify. Left ventricular dysfunction often precedes symptoms, needing active surveillance by echocardiography to determine the optimum time for aortic valve replacement. Development of transcatheter approaches for aortic regurgitation is challenging, owing to the absence of valvular calcification and distortion of aortic root anatomy in many patients.

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

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

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