Author + information
- Tomohiko Taniguchi, MD,
- Takeshi Morimoto, MD, MPH,
- Ryuzo Sakata, MD and
- Takeshi Kimura, MD∗ ()
- ↵∗Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
Several important issues were raised on our recent paper from the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients with Severe Aortic Stenosis) registry (1) by these 4 letters. Although severe AS was defined according to the guidelines (2) in this study (Vmax >4.0 m/s, mean aortic pressure gradient [PG] >40 mm Hg, or aortic valve area [AVA] <1.0 cm2), those patients included on the basis of AVA <1.0 cm2 alone with less severe Vmax and mean gradient might have confounded the study results. We performed a sensitivity analysis in 816 asymptomatic patients with a high gradient (Vmax >4.0 m/s or mean aortic PG >40 mm Hg) using a Cox proportional hazard models with the same risk-adjusting variables except for Vmax ≥4 m/s, which demonstrated the lower risk of an initial aortic valve replacement (AVR) strategy relative to a conservative strategy for all-cause death and heart failure hospitalization, which was consistent with the results in the entire study population (Table 1).
We did not collect the information on the exercise test in asymptomatic patients with severe AS. Although exercise testing is recommended in asymptomatic patients with severe AS in the current guidelines, this recommendation was based on previous studies that included patients 70 years of age or younger who were expected to perform exercise testing. In the present study, patients in the conservative group were much older (mean age: 77.8 years old; 46% were older than 80 years) than in the previous studies that evaluated the importance of exercise testing. We believe that exercise testing is not commonly performed in real-world clinical practice due to concerns about safety, and that it could not be performed in a satisfactory manner in many patients with asymptomatic severe AS because of their advanced age, limited exercise capacities, frailties, and comorbidities.
Periodic echocardiographic follow-up according to the current guidelines was performed in 62% of patients in the conservative group, suggesting fairly close follow-up in real-world clinical practice.
Definitive conclusions regarding the superiority of the initial surgical or transcatheter AVR strategy over conservative strategy in asymptomatic patients with severe AS should be drawn by the randomized controlled trials. We have a great interest in the AVATAR (Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis) trial, which was carefully designed to enroll truly asymptomatic patients with severe AS. Before waiting for the trial result, we should be more careful in evaluating patients’ symptoms, and in conducting close echocardiographic follow-up to not lose the opportunity to perform early AVR.
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.
- Nishimura R.A.,
- Otto C.M.,
- Bonow R.O.,
- et al.