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Treatment of asymptomatic aortic valve stenosis

Watchful waiting or early intervention?

Behandlung der asymptomatischen Aortenklappenstenose

„Watchful waiting“ oder frühe Intervention?

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Abstract

There is ongoing debate about the optimal management of severe asymptomatic aortic stenosis (AS). Thus far, current guidelines recommend a watchful waiting strategy for the majority of asymptomatic patients. However, data on the prognosis of asymptomatic AS are inconsistent. Some reports claim an increased risk of complications and even mortality in this subset of patients when treated conservatively. Several factors are considered to contribute to the impaired outcome of asymptomatic patients, such as progressive myocardial damage or sudden cardiac death, during the watchful waiting period. Indeed, a few nonrandomized studies are available in the literature showing improved survival with early aortic valve replacement during the asymptomatic phase compared with watchful waiting. However, these studies have several limitations particularly with regard to methodology, and thus making a clear recommendation on treatment options impossible. Therefore, randomized controlled trials are urgently needed in order to treat these patients on the basis of adequate evidence.

Zusammenfassung

Es wird nach wie vor über das optimale Management von Patienten mit schwerer asymptomatischer Aortenklappenstenose diskutiert. Bisher empfehlen die Leitlinien bei einem Großteil dieser Patienten eine „Watchful-waiting-Strategie“. Allerdings sind die Daten bezüglich der Prognose der asymptomatischen Aortenklappenstenose widersprüchlich. Einige Publikationen zeigen ein erhöhtes Risiko von Komplikationen und sogar Mortalität, wenn diese Patienten konservativ behandelt werden. Mehrere Faktoren wie beispielsweise ein progredienter Myokardschaden als Folge der permanent erhöhten Nachlast oder plötzlicher Herztod während des „watchful waiting“ tragen vermutlich zu einem schlechteren Ergebnis asymptomatischer Patienten bei. Es existieren einige nichtrandomisierte Studien, die tatsächlich ein verbessertes Überleben mit einem frühen Aortenklappenersatz während der asymptomatischen Phase verglichen mit „watchful waiting“ zeigen. Jedoch haben diese Studien eine Vielzahl an Limitationen, insbesondere bezüglich der Methodik. Daher kann aus diesen Daten keine eindeutige Empfehlung für eine der therapeutischen Optionen abgeleitet werden. Aus diesem Grund sind randomisierte Studien in diesem Indikationsgebiet dringend erforderlich.

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Authors and Affiliations

  1. Medical Clinic II (Medical Clinic II, Department of Cardiology, Angiology, Intensive Care Medicine), University Heart Center Lübeck, Universitätsklinikum Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany

    J. Ledwoch &  H. Thiele

  2. Partner Site Hamburg/Kiel/Lübeck, German Center for Cardiovascular Research (DZHK), Lübeck, Germany

    J. Ledwoch &  H. Thiele

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  1. J. Ledwoch
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  2. H. Thiele
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Correspondence to H. Thiele.

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J. Ledwoch and H. Thiele declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Ledwoch, J., Thiele, H. Treatment of asymptomatic aortic valve stenosis. Herz 42, 528–535 (2017). https://doi.org/10.1007/s00059-017-4584-z

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