Temerty Faculty of Medicine, 1 King's College Circle, Toronto, ON M5S1A8, Canada.
Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd a3600, Los Angeles, CA 90048, USA.
Eur Heart J. 2023 Mar 7;44(10):796-812. doi: 10.1093/eurheartj/ehac803.
Aortic stenosis (AS) is a serious and complex condition, for which optimal management continues to evolve rapidly. An understanding of current clinical practice guidelines is critical to effective patient care and shared decision-making. This state of the art review of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines and 2020 American College of Cardiology/American Heart Association Guidelines compares their recommendations for AS based on the evidence to date. The European and American guidelines were generally congruent with the exception of three key distinctions. First, the European guidelines recommend intervening at a left ventricular ejection fraction of 55%, compared with 60% over serial imaging by the American guidelines for asymptomatic patients. Second, the European guidelines recommend a threshold of ≥65 years for surgical bioprosthesis, whereas the American guidelines employ multiple age categories, providing latitude for patient factors and preferences. Third, the guidelines endorse different age cut-offs for transcatheter vs. surgical aortic valve replacement, despite limited evidence. This review also discusses trends indicating a decreasing proportion of mechanical valve replacements. Finally, the review identifies gaps in the literature for areas including transcatheter aortic valve implantation in asymptomatic patients, the appropriateness of Ross procedures, concomitant coronary revascularization with aortic valve replacement, and bicuspid AS. To summarize, this state of the art review compares the latest European and American guidelines on the management of AS to highlight three areas of divergence: timing of intervention, valve selection, and surgical vs. transcatheter aortic valve replacement criteria.
主动脉瓣狭窄（AS）是一种严重且复杂的疾病，其最佳治疗方法仍在不断快速发展。了解当前的临床实践指南对于有效的患者护理和共同决策至关重要。本综述对 2021 年欧洲心脏病学会/欧洲心胸外科学会指南和 2020 年美国心脏病学会/美国心脏协会指南进行了深入分析，比较了基于现有证据，这两个指南对 AS 的推荐建议。除了三个关键区别之外，欧洲和美国的指南通常是一致的。首先，欧洲指南建议在左心室射血分数为 55%时进行干预，而美国指南建议在无症状患者中通过连续成像时达到 60%。其次，欧洲指南建议手术生物瓣的阈值为≥65 岁，而美国指南则采用了多个年龄类别，为患者因素和偏好提供了一定的灵活性。第三，尽管证据有限，但指南支持经导管主动脉瓣置换与手术主动脉瓣置换的不同年龄标准。本文还讨论了一些趋势，表明机械瓣置换的比例正在下降。最后，该综述确定了一些文献中的空白领域，包括无症状患者的经导管主动脉瓣植入术、Ross 手术的适宜性、主动脉瓣置换术同期冠状动脉血运重建术以及二叶式主动脉瓣狭窄。总之，本综述比较了最新的欧洲和美国 AS 管理指南，突出了三个分歧领域：干预时机、瓣膜选择以及经导管与手术主动脉瓣置换标准。
