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Ann Thorac Surg 2007;84:355-356
© 2007 The Society of Thoracic Surgeons

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Correspondence

Asymptomatic Aortic Valve Stenosis: To Operate or Not to Operate?

Angelo De Gasperis Department of Cardiac Surgery, Niguarda Cà Granda Hospital, P.zza Ospedale Maggiore, 3, Milan, 20162 Italy

(Email: aldo.cannata{at}libero.it).

To the Editor:

We read with great interest the article by Pai and colleagues [1] about the natural history of asymptomatic aortic valve stenosis (AS). We congratulate the authors for their study, including a large and well-characterized population and focus on a controversial issue with important clinical and medico-legal implications. According to the results of their observational study, they stated that the natural history of asymptomatic AS is not benign and that survival is dramatically improved by surgical treatment. They defined the patients that had no cardiac symptoms at the initial evaluation as asymptomatic. Then they conducted a retrospective study on these patients with a mean follow-up period of 3.5 years and an observation period of up to more than 10 years. It seems that besides the initial evaluation there is not any data about the development of symptoms during follow-up. Nevertheless, as remembered also by Pai and colleagues [1] it is well-known that disease progression with onset of symptoms is very common in AS [2]. Therefore it is very likely that a significant number of patients followed by the authors did develop symptoms in time, with worsening of the prognosis without surgery. In our opinion, the presence of this subgroup of patients, apparently not described but still classified by the authors as asymptomatic, can be misleading, because it may determine an overestimate of the mortality among the really asymptomatic patients. Moreover the authors did not explain why asymptomatic patients underwent aortic valve replacement in 29% of cases. Were they still asymptomatic at surgery or did they become symptomatic during follow-up? In our opinion, the interpretation of these results from this very interesting study seems to suggest prudence in lowering the threshold to aortic valve replacement in absence of symptoms. This still remains a difficult decision of whether to operate or not on asymptomatic patients. Recently, the American College of Cardiology/American Heart Association classified aortic valve replacement as a class III recommendation for isolated, asymptomatic severe calcified AS [2]. It is likely that more than randomized trials are needed; we need very close and watchful clinical follow-up of these patients for early detection of symptom onset [2, 3].

	References

Top References

 

1. Pai RG, Kapoor N, Bansal RC, Varadarajan P. Malignant natural history of asymptomatic severe aortic stenosis: benefit of aortic valve replacement Ann Thorac Surg 2006;82:2116-2122.[Abstract/Free Full Text]
2. Bonow RO, Carabello BA, Kanu C, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons Circulation 2006;114:e84-e231.[Free Full Text]
3. Otto CM. Valvular aortic stenosis: disease severity and timing of intervention J Am Coll Cardiol 2006;47:2141-2151.[Abstract/Free Full Text]

This article has been cited by other articles:

				R. G. Pai and P. Varadarajan Reply. Ann. Thorac. Surg., July 1, 2007; 84(1): 356 - 357. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pasquale Fratto Ettore Vitali Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cannata, A. Articles by Vitali, E. Search for Related Content PubMed PubMed Citation Articles by Cannata, A. Articles by Vitali, E. Related Collections Valve disease Related Article