Asymptomatic Aortic Stenosis: When to Operate?

Although there is general agreement that symptomatic aortic stenosis (AS) requires urgent surgery, it remains controversial when to operate on asymptomatic but nevertheless severe AS. Current practice guidelines recommend valve replacement in patients in asymptomatic when the systolic left ventricular function is found to be reduced without other explanation. Otherwise, surgery should be or at least may be considered (recommendation classes IIa or IIb) in asymptomatic patients with severe AS and an abnormal exercise test, a high likelihood of rapid progression, or very severe AS in the presence of low surgical risk. This article reviews recent publications evaluating early elective surgery versus watchful waiting as recommended by current guidelines. The second focus of this review is on new insights on predictors of outcome in asymptomatic AS that may improve timing of surgery and therefore deserve to be considered in future recommendations for the treatment of this difficult patient group.     

Drugs for Prevention and Treatment of Aortic Stenosis: How Close Are We?

Aortic stenosis is one of the most common cardiovascular diseases in the world. Extensive work on the underlying pathophysiology responsible for calcific aortic valve disease and its progression to aortic stenosis has described a complex process involving inflammation, lipid deposition, mineralisation, and genetic factors such as elevated lipoprotein(a). With the advancement of gene silencing technology and development of novel therapeutic agents, we may now be closer than ever to having medical therapies that prevent, or at least slow the progression of aortic stenosis. In this review, we highlight the pathophysiology and risk factors of calcific aortic valve disease, along with current, potential, and emerging novel medical therapies. We also provide potential explanations for the failure of statin trials and suggest new avenues for research and new randomised trials in this area.