Académie royale de Médecine de Belgique

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Résumé Patrizio Lancellotti

NEW INSIGHTS INTO AORTIC STENOSIS : GRADING AND STAGING THE DISEASE  

par  Patrizio LANCELLOTTI (University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU Sart Tilman, Liège), invité.      

Calcific aortic valve stenosis (AS) is the most common valvular heart disease in western countries. As aortic valve fibrosis and calcification develop and advanced calcific aortic valve stenosis (AS) sets in, 75% of patients will develop heart failure, undergo valve replacement, or die within five years. Current guidelines require that symptoms related to the valve disease be present for consideration of transcatheter aortic-valve replacement (TAVR) or surgical aortic-valve replacement in AS. There are two important unsettled issues with regard to timing of intervention in severe AS. One has to do with the reliability of symptoms as the trigger for SAVR or TAVR. And the other related issue has to do with identification of signal (s) for intervention in asymptomatic severe AS. These signals could be related to the biology of the stenotic aortic valve or the effects of the stenotic AV on the structure and function of the left ventricle (LV) or both. Hence, the concept of staging the disease rather than merely classifying AS based on Doppler hemodynamic severity has recently emerged. This means that among severe AS there may be a compensated (stage 0-1), subclinical decompensation and decompensated stage (stage 3-4). In this schema, stages 0 and 1 are where one is likely to encounter individuals with severe AS but who truly do not have symptoms at rest or exercise. These two stages are predominantly defined by the state of the structure and function of the LV, other than the hemodynamic severity of the AS. Among the structural changes of the LV in severe AS, hypertrophy (LVH) and increased mass are the most recognizable morphological changes. Staging the disease includes assessing non-valve-related structural abnormalities of the heart, considering other hemodynamic cardiac abnormalities and assessing the biomarker profile. This multi-pronged method integrates assessment of risk-based disease severity and disease progression, and permits the formulation of a follow-up and management scheme for each patient with AS (Figure 1).

Reference

1.    Lancellotti P, Vannan MA. Timing of Intervention in Aortic Stenosis. N Engl J Med. 2020;382:191-193. https://www.nejm.org/doi/full/10.1056/NEJMe1914382

 

 

Figure 1: An Approach to Staging in Severe Aortic Stenosis

 

 

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