Author + information
- Marko Banovic, MD, PhD∗ (, )
- Serge D. Nikolic, PhD and
- Svetozar Putnik, MD, PhD
- ↵∗Belgrade Medical School, University of Belgrade, 11000 Belgrade, Serbia
We have carefully, and with great interest, read the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients with Severe Aortic Stenosis) registry data by Taniguchi et al. (1), which was published in a previous issue of the Journal, and the editorials written by world-renowned experts, Dr. Bonow (2) and Drs. Eneid and Pellikka (3). The summary conclusion from all these papers is that a prospective, randomized trial in asymptomatic patients with isolated severe aortic stenosis (AS) is much needed to ascertain whether we can provide better treatment for these patients. As Dr. Bonow observed, the CURRENT AS registry is “about as good as it gets in shedding more light on this issue.” The subheading in the editorial by Eleid and Pellikka, “What Are We Waiting For?” is especially interesting. Our answer is that we are not waiting any more.
A group of cardiologists and cardiac surgeons from several European countries have started the AVATAR (Aortic Valve Replacement versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) trial, which is a randomized, multicenter-controlled, event-driven trial. The study has been registered at clinicaltrials.gov (NCT02436655) and has already started. The first 10 randomized patients have already been included in the study. We believe that the AVATAR trial (4), which is to the best of our knowledge, the first prospective randomized trial in asymptomatic patients with isolated severe AS and with normal left ventricular ejection fraction (>50%), will overcome all the drawbacks identified in the useful and well-designed Japanese registry (1), that is, its retrospective nature, reliance on aortic valve area as a main parameter to diagnose severe AS, and the large disproportion between patients who underwent electively surgery and patients who underwent surgery after symptom onset. The advantages of the AVATAR trial include randomization, stress testing to prove the asymptomatic status of the patient, comprehensive analysis to confirm the absence of serious comorbidities and the absence of coronary artery disease needing revascularization, close follow-up that will enable all patients that are randomized to “watchful waiting” to be promptly referred to surgery after symptom onset, and a safety analysis that will compare the results of elective surgery (treatment group) versus surgery after symptom onset (watchful waiting group).
Regardless of the AVATAR trial results, we believe this study will be an important step forward in addressing the question of whether early aortic valve replacement is preferable to a watchful waiting strategy.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Taniguchi T.,
- Morimoto T.,
- Shiomi H.,
- et al.
- Bonow R.
- Eleid M.F.,
- Pellikka P.