Key result
Watchful waiting in asymptomatic aortic stenosis carries ~41% 10-year mortality, with few remaining intervention-free.
Why the study?
While extravalvular cardiac damage staging has been shown to assess short- and mid-term prognosis in aortic stenosis, the long-term prognosis of patients with asymptomatic moderate-to-severe AS and the utility of cardiac damage staging in this scenario remained to be determined.
Does baseline staging by extravalvular cardiac damage predict 10-year mortality and clinical outcomes in patients with asymptomatic moderate-to-severe aortic stenosis managed with watchful waiting?
Cohort (n=96)
Does baseline staging by extravalvular cardiac damage predict 10-year mortality and clinical outcomes in patients with asymptomatic moderate-to-severe aortic stenosis managed with watchful waiting?
In patients with asymptomatic moderate-to-severe aortic stenosis managed with watchful waiting, 10-year mortality is high (40.6%, mostly non-cardiac), and baseline extravalvular cardiac damage staging helps identify a small subset of patients (~10%) who remain asymptomatic and free from valve intervention at 10 years.
Substantial 10-year mortality with watchful waiting in asymptomatic AS warrants caution; hypothesis-generating for cardiac damage staging to identify low-risk subsets.
Background/Introduction Some studies have shown that patients with aortic stenosis (AS) have a poor prognosis, even when the stenosis is moderate (1,2). Extravalvular staging has been shown to be a useful tool for assessing the short- and mid-term prognosis of these patients (3) Purpose To determine the long-term prognosis of a cohort of patients with asymptomatic moderate-to-severe aortic stenosis and to assess whether staging by cardiac damage (CD) is useful in this scenario. Methods We prospectively included 96 consecutive patients with asymptomatic moderate or severe AS in a dedicated registry in 2014. Baseline assessment comprised comprehensive echocardiography, cardiopulmonary exercise testing, blood biomarkers, cardiac magnetic resonance and computed tomography aortic valve calcium scoring. Patients were classified into 5 stages of cardiac damage (0-4)(3) at baseline, a classification in which stage 0 indicates no extravalvular involvement and stage 4 reflects right heart involvement. Stages 3 and 4 were merged for statistical purposes due to the small number of patients in each group. Follow-up was at the treating cardiologist’s discretion, and aortic valve replacement (AVR) was decided by the Heart Team according to current guidelines, using a watchful waiting strategy. Data on AVR, mortality, and heart failure hospitalization were collected retrospectively. Results The baseline characteristics of the cohort were: mean age 71 years; 72% male; 71% with hypertension; 55% with dyslipidemia; 55% with diabetes mellitus; mean aortic valve area (AVA) 1.04 cm²; and mean aortic gradient 39 mmHg. During follow-up, 20 patients (20.8%) developed symptoms within the first year and 68 (70.8%) became symptomatic at some point. 67 patients (69.8%) underwent surgical or transcatheter AVR, and 25 (26%) required hospitalization for heart failure before AVR, while heart failure occurred in 12 patients (12.5%) after AVR. At 10 years, 39 patients (40.6%) had died, of whom 15 died from cardiovascular causes; cancer was the most frequent cause of death. Of 11 patients (11.5%) that remained alive and free from AVR after 10 years of follow up, 9 were still asymptomatic; compared with the rest of the cohort, they were younger (71 vs 64 years. p= 0,04), had less severe baseline AS (mean gradient: 40 mmHg vs 30 mmHg. p= 0,008) and showed minimal or no extravalvular cardiac damage at baseline (9 of 11 patients were at stage 0). Statistically significant differences in 10-year all-cause mortality were observed according to baseline CD staging. Conclusions Ten-year mortality in patients with asymptomatic moderate/severe aortic stenosis managed with watchful waiting and Heart Team–guided intervention is high and mostly driven by non-cardiac causes. Extravalvular CD staging identified a small subset of patients with a markedly better long-term prognosis, with about 10% of the cohort remaining asymptomatic and free from valve intervention at 10 years.10 year Kaplan–Meier survival by stageMortality and intervention rates by stage
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Rodriguez et al. (2026) conducted a cohort in Asymptomatic moderate-to-severe aortic stenosis (n=96). Extravalvular cardiac damage staging (stages 0-4) with watchful waiting strategy vs. Stage 0 (no extravalvular cardiac damage) vs stages 1-4 was evaluated on 10-year all-cause mortality and aortic valve replacement. Watchful waiting in asymptomatic moderate-to-severe aortic stenosis resulted in 40.6% 10-year mortality and 69.8% AVR, with baseline stage 0 cardiac damage identifying the 11.5% surviving AVR-free.
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