Karampinos Konstantinos, Ktenopoulos Nikolaos, Apostolos Anastasios, Koliastasis Leonidas, Kachrimanidis Ioannis, Vlachakis Panayotis, Katsaros Odysseas, Tsalamandris Sotirios, Karanasos Antonios, Drakopoulou Maria, Synetos Andreas, Latsios George, Tsioufis Konstantinos, Toutouzas Konstantinos
First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, Athens 11527, Greece.
First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, Athens 11527, Greece.
Hellenic J Cardiol. 2025 Jun 16. doi: 10.1016/j.hjc.2025.06.004.
Aortic stenosis (AS) remains the leading valvular heart disease worldwide, affecting up to 5% of older adults and posing a significant risk if left untreated. The evolution of transcatheter aortic valve replacement (TAVR) and its expanding indications for symptomatic patients with severe AS, coupled with the evolving understanding of the pathophysiology and natural history of AS, have heightened the focus on asymptomatic patients with severe AS. Although current clinical practice guidelines recommend aortic valve replacement (AVR) therapy in asymptomatic severe aortic stenosis (ASAS) only in specific clinical settings, recent studies have challenged traditional treatment paradigms, advocating for a more individualized strategy, particularly for patients exhibiting high-risk characteristics. In this review, we provide an in-depth analysis of ASAS, focusing on the intricacies of its clinical management, novel risk-stratification modalities, and predictors of symptom onset and disease progression. We also determine the role of echocardiography in assessing AS severity, highlighting inconsistencies in diagnostic criteria and the need for supplementary testing. Evolving and recently published randomized controlled trials-namely EARLY-TAVR, EVoLVeD, and TAVR-UNLOAD-randomizing asymptomatic patients to early intervention or a watchful waiting strategy provide significant evidence that has the potential to change treatment paradigms, lower the threshold for intervention, and pave the way for more individualized management strategies in ASAS.
主动脉瓣狭窄（AS）仍是全球主要的心脏瓣膜疾病，影响着高达5%的老年人，若不治疗则会带来重大风险。经导管主动脉瓣置换术（TAVR）的发展及其对有症状的重度AS患者适应症的不断扩大，再加上对AS病理生理学和自然病史认识的不断演变，使得对无症状重度AS患者的关注日益增加。尽管当前临床实践指南仅在特定临床情况下推荐对无症状重度主动脉瓣狭窄（ASAS）患者进行主动脉瓣置换（AVR）治疗，但近期研究对传统治疗模式提出了挑战，主张采用更个体化的策略，尤其是对于具有高风险特征的患者。在本综述中，我们对ASAS进行了深入分析，重点关注其临床管理的复杂性、新的风险分层模式以及症状发作和疾病进展的预测因素。我们还确定了超声心动图在评估AS严重程度中的作用，强调了诊断标准的不一致性以及补充检查的必要性。正在进行和最近发表的随机对照试验——即EARLY-TAVR、EVoLVeD和TAVR-UNLOAD，将无症状患者随机分为早期干预组或观察等待组，提供了重要证据，有可能改变治疗模式，降低干预阈值，并为ASAS中更个体化的管理策略铺平道路。
