Considerations for lifetime management of aortic stenosis: Transcatheter aortic valve replacement, surgical aortic valve replacement, and timing of therapy

Severe aortic valve stenosis (AS) is the primary reason for heart valve intervention in Europe and the United States, 1 affecting 52.5 individuals (95% confidence interval [CI], 49.4-55.8)per 100,000 patient-years. 2 The management of AS has evolved dramatically in recent years driven by advancements in treatment modalities and a deeper understanding of disease progression and its impact on survival and quality of life.While elderly, frail patients with a high burden of comorbidities were previously considered inoperable or at high surgical risk for surgical aortic valve replacement (SAVR), the landscape of AS management has been revolutionized by the introduction of transcatheter aortic valve replacement (TAVR). 3ver the last decade, TAVR has evolved from an experimental procedure to a treatment option that has demonstrated superiority or at least noninferiority compared to SAVR across all surgical risks. 4,5The decision between SAVR and TAVR should consider not only surgical risk and patient age, but also a range of clinical, anatomic, and procedural factors.These include the feasibility of a transfemoral approach, risk of requiring a pacemaker, and potential procedural complications.Another critical consideration is the risk of structural and nonstructural valve degeneration, which influences the likelihood of future reinterventions and necessitates balancing transcatheter heart valve (THV) durability with the patient's life expectancy.Consequently, such factors as the risk of coronary obstruction, limitations in coronary reaccess, and the feasibility of leaflet modification techniques must be carefully evaluated.These factors impact both short-and long-term outcomes and have critical roles in the decision making process.This article explores current considerations in the lifetime management of AS, highlighting evolving treatment paradigms and emphasizing a patient-centered approach. TIMING OF INTERVENTIONAS is characterized by progressive thickening, fibrosis, and calcification of the valve leaflets, leading to valve flow restriction, increased left ventricular (LV) afterload, and a consequent hypertrophic response to maintain cardiac output.However, as stenosis progresses, this hypertrophic response eventually decompensates, resulting in symptom development, heart failure, and death. 6espite the incorporation of various drugs in heart failure guideline-directed medical therapy, no medications have been proven to slow or reverse AS progression.