Treatment in patients with severe asymptomatic aortic stenosis: is it best not to wait?

New insights into the natural history and pathophysiology of patients with aortic stenosis (AS), coupled with the dramatic evolution of transcatheter aortic valve implantation (TAVI), are fuelling intense interest in the management of asymptomatic patients with severe AS. This patient presenting for elective intervention poses a unique challenge. These patients are not traditionally offered surgical aortic valve replacement or TAVI given their lack of symptoms; however, they are at increased risk given the severity of their AS. Furthermore, clinical experience has shown that symptoms can be challenging to ascertain in many sedentary, deconditioned, and/or elderly patients. In addition, evolving data based on imaging and biomarker evidence of adverse ventricular remodelling, hypertrophy, inflammation, or fibrosis may radically transform existing clinical decision paradigms. However, management of asymptomatic severe AS is otherwise controversial and the decision to intervene requires careful assessment of the benefits and risks in an individual patient. Further randomized trials [EARLY TAVI (NCT03042104), AVATAR (NCT02436655), EVOLVED (NCT03094143)] will help determine future recommendations.

Electrocardiographic appearance of aortic stenosis before and after aortic valve replacement.

BACKGROUND: So far, the specific appearance of QRS complex, ST-segment, and T wave was observed in aortic stenosis (AS). S-wave dynamic change in leads V1 -V3 was not reported in AS. METHODS: In a single-center, prospective study, we included a total number of 1.175 patients who underwent surgical aortic valve replacement (AVR). We conducted 3-year gathering of patients with symptomatic and asymptomatic severe AS, and separated them by hemodynamic stability into groups A and B, through EFLV (of more or less than 50%), AVA (of more or less than 0.9 cm2 ), PG (between 55 and 75 mm Hg or over 75 mm Hg), and end-diastolic LV dimension (of more or less than 56 mm). We evaluated the impact of S-wave magnitude in right precordial leads before and after AVR in all patients. We followed S-wave changes in electrocardiogram altogether with hemodynamic measurements derived from echocardiography. RESULTS: Analysis of echocardiographic parameters, measured in patients before surgery, did not show statistical significance between asymptomatic and symptomatic group. The statistical significance was observed in the change in S-wave magnitude in the right precordial leads in both subsets of patients before AVR. We found statistically significant predictive value of S-wave magnitude in leads V2 -V3 for dependent variables PG and end-diastolic LV dimension. CONCLUSIONS: S-wave changes in right precordial leads can predict increase in PG and critical narrowing of AVA, suggestive of timely referral for AVR.

Staged Versus Concomitant Carotid Endarterectomy and Aortic Valve Replacement: A Case Report and Literature Review.

Stroke is a common complication of cardiac surgery, and carotid artery stenosis is an established risk factor for stroke. Therefore, patients with carotid artery stenosis who are undergoing cardiac surgery require proper management of the former either simultaneously or before cardiac surgery. We present a challenging case of a 67-year-old male patient who presented with generalized weakness, severe aortic stenosis, and significant bilateral carotid artery stenosis. The coexistence of these findings sparked a debate about whether to perform a carotid endarterectomy first or an aortic valve replacement. Moreover, a past history of percutaneous coronary intervention and coronary artery bypass grafts made the decision more challenging. Multiple approaches have been employed for the management of coexisting carotid artery stenosis with cardiac surgery; however, no definitive guidelines exist, especially for surgeries other than coronary artery bypass grafts or where the carotid stenosis is bilateral and severe.

Asymptomatic Severe Aortic Stenosis: Contemporary Evaluation and Management.

Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries and most prevalent in the elderly. According to the current guidelines, intervention is recommended in symptomatic severe AS; however, in asymptomatic patients, aortic valve replacement (AVR) is considered when symptoms appear or the left ventricular dysfunction occurs, but the evidence supports these indications are poor. The optimal timing and modality of intervention in asymptomatic severe AS (ASAS) remain controversial. Earlier AVR in certain scenarios has been increasingly supported by some groups before subclinical irreversible myocardial damage occurs. In addition, the continuous advancement of percutaneous and surgical approaches where associated with a substantial decrease in mortality and perioperative complications which made many authors advocate for early intervention in those patients. Our review highlights the contemporary evaluation and management of ASAS and summarizes the current scientific evidence regarding optimal timing for intervention and indications for early AVR in such patients.

Prognostic Value of Global Longitudinal Strain in Asymptomatic Aortic Stenosis: A Systematic Review and Meta-Analysis.

BACKGROUNDS: The presence of impaired global longitudinal strain (GLS) may be a valuable bio-marker in the early diagnosis for left ventricle (LV) impairment, which would help scrutinize asymptomatic aortic stenosis (AS) patients with high risk of adverse outcomes, such as major adverse cardiovascular events (MACE). METHODS: The study was prospectively registered in PROPSERO (CRD 42021223472). Databases, such as Pubmed, Embase, Cochrane Library, Web of science, and Scopus were searched for studies evaluating the impact of impaired GLS on MACE, all-cause mortality, and aortic valve replacement (AVR) in asymptomatic AS. Hazard ratios (HRs) with 95% CIs were calculated with meta-analysis for binary variants. Meta-regression, subgroup analysis, and sensitivity analyses were applied as needed to explore the heterogeneity. RESULTS: Eventually, a total of nine studies reporting 1,512 patients were enrolled. Compared with the normal GLS group, impaired GLS significantly increased MACE (HR = 1.20, 95% CI: 1.10-1.30, I 2 = 79%) with evident heterogeneity, all-cause mortality (HR = 1.42, 95% CI: 1.24-1.63), and AVR (HR = 1.17, 95% CI: 1.07-1.28). Subgroup analyses stratified by left ventricular ejection fraction (LVEF) > 50% or LVEF without precise cut-off point found that compared with the normal GLS group, impaired GLS remarkably increased MACE both in two subgroups (LVEF > 50%: HR: 1.22, 95% CI: 1.05-1.50; LVEF without cutpoint: HR: 1.25, 95% CI: 1.05-1.50). The results stratified by AS severity (mild/moderate and severe) or follow-up time resembled those stratified by LVEF. In addition, when subgroup analysis was stratified by mean aortic valve pressure gradient (MG ≥ 40 mm Hg and MG <40 mm Hg), compared with normal GLS, impaired GLS significantly increased MACE both in two subgroups (MG ≥ 40 mm Hg: HR: 3.41, 95% CI: 1.64-7.09; MG below 40 mm Hg: HR: 3.17, 95% CI: 1.87-5.38). Moreover, the effect sizes here were substantially higher than those in the former two stratified factors. CONCLUSIONS: The presence of impaired GLS substantially worsens the outcomes for adverse cardiovascular events in asymptomatic patients with AS regardless of LVEF or AS severity or follow-up time or mean aortic valve pressure gradient, which highlights the importance of incorporating impaired GLS into risk algorithms in asymptomatic AS. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (registration number: CRD42021223472).

Severe Aortic Stenosis: More Than an Imaging Diagnosis.

The definition of severe aortic stenosis has undergone significant change casting a wider net to avoid missing patients who could benefit from valve replacement. The presence or absence of symptoms remains the key decision-making element; however, individuals presently undergoing evaluation are older, more likely asymptomatic, and have lower gradients. Due to numerous potential measurement errors, attention to detail when performing diagnostic testing and understanding their limitations are necessary to render appropriate treatment. Exercise testing adds useful information for individuals with severe aortic stenosis felt to be asymptomatic. Dobutamine echocardiography, in low flow-low gradient aortic stenosis, distinguishes between a myopathic and valvular cause of left ventricular dysfunction. Evaluation of patients when normotensive minimizes measurement errors. The amount of aortic valve calcification adds useful information when the degree of aortic stenosis is uncertain. A good history and physical integrated with high-quality imaging data allows for appropriate clinical treatment decisions for patients with aortic stenosis. The goal is simultaneously to provide aortic valve replacement for patients in need while avoiding overdiagnosis and performance of unnecessary procedures.

Surgical Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: An Updated Systematic Review and Meta-Analysis.

BACKGROUND: While aortic valve replacement (AVR) is indicated for symptomatic severe aortic stenosis (AS), the appropriate management of asymptomatic severe AS remains unclear. We conducted an updated meta-analysis to compare the outcomes of surgical AVR (SAVR) versus conservative treatment in patients with asymptomatic severe AS. METHODS: We searched PubMed, EMBASE, Cochrane, clinicaltrials.gov, and Google Scholar for studies comparing outcomes of SAVR versus conservative treatment in asymptomatic severe AS. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each individual study. Outcomes included all-cause mortality, cardiovascular and non-cardiovascular mortality, 30-day operative mortality, sudden cardiac death (SCD), heart failure hospitalization (HFH), myocardial infarction (MI), and stroke. RESULTS: A total of 8 studies with 2685 patients were included. The mean age was above 60 years, and the median follow-up duration was 4 years. Compared to conservative treatment, SAVR was associated with significantly lower all-cause mortality (RR 0.39; 95% CI 0.23-0.64) and HFH rates (RR 0.18; 95% CI 0.05-0.71). There were no significant differences in cardiovascular mortality (RR 0.24; 95% CI 0.03-1.67), non-cardiovascular mortality (RR 0.49; 95% CI 0.23-1.03), 30-day operative mortality (RR 0.48; 95% CI 0.10-2.32), SCD (RR 0.37; 95% CI 0.05-2.89), MI (RR 0.48; 95% CI 0.04-5.52), and stroke rates (RR 1.20; 95% CI 0.35-4.11) between the two strategies. CONCLUSIONS: In patients with asymptomatic severe AS, SAVR is associated with significantly lower all-cause mortality and HFH compared to conservative treatment. While SAVR is a promising option for asymptomatic severe AS, most studies were observational and nonrandomized; randomized trials are needed to establish a clear benefit.

Early surgery vs conservative management among asymptomatic aortic stenosis: A systematic review and meta-analysis.

Introduction: Although aortic valve replacement in severe symptomatic Aortic Stenosis (AS) are clearly outlined, the role of surgical intervention in asymptomatic severe AS remains unclear with limited evidence. The aim of our meta-analysis is to evaluate the efficacy and safety of early surgical aortic valve repair compared to conservative management. Methods: A systematic literature search was performed in PubMed, Scopus, Embase and Cochrane databases for studies comparing the early surgery versus conservative management among asymptomatic aortic stenosis patients. Unadjusted odds ratios (OR) were pooled using a random-effect model, and a p-value of < 0.05 was considered statistically significant. Results: A total of 5 articles (3 observational studies and 2 randomized controlled trials) were included. At a median followup of 4.1 years, here were significantly lower odds of all-cause mortality [OR = 0.30 (95 %CI:0.17-0.53), p < 0.0001], cardiovascular mortality [OR = 0.35 (95 %CI:(0.17-0.72), p = 0.005], and sudden cardiac death (OR = 0.36 (95 %CI: 0.15-0.89), p = 0.03) among early surgery group compared with conservative care. There was no significant difference between incidence of major bleeding, clinical thromboembolic events, hospitalization due to heart failure, stroke and myocardial infarction between the conservative care groups and early surgery. Conclusion: Among asymptomatic patients with AS, early surgery shows better outcomes in reducing all-cause mortality and cardiovascular mortality compared with conservative management approaches.

Asymptomatic patients with very severe aortic stenosis-operate or watch?

The Randomized Comparison of Early Surgery versus Conventional Treatment in Very Severe Aortic Stenosis (RECOVERY) trial has for the first time compared the strategy of surgery or observation in a randomized fashion. This was a prospective, randomized, multi-center trial that included 145 patients in total. Median follow-up was for just over 6 years. During follow-up, the rate of sudden death was 14% at 8 years in the conservative strategy group and 74% of the patients crossed over from the conservative treatment to the surgery arm. The main issues with the trial were inclusion of patients who may have already met the class IIa criteria for aortic valve replacement, as well as inability to accurately assess patients for presence of symptoms at the time of randomization. While the trial confirms that patients with very severe aortic stenosis do have a poor long-term outcome, because of the study design limitations, it does not confirm a definitive argument for early intervention.

Prognostic Value of the Three-Dimensional Right Ventricular Ejection Fraction in Patients With Asymptomatic Aortic Stenosis.

Background: The right ventricular (RV) function is an important prognostic marker of asymptomatic aortic stenosis (AS). However, previous publications have not addressed the additive value of conventional RV parameters over left heart parameters. Whether three-dimensional echocardiography (3DE)-derived RV ejection fraction (RVEF) has prognostic utility independent of 3DE derived left heart parameters is also unknown. We investigated the prognostic utility of 3DE RVEF in patients with asymptomatic AS. Methods: We retrospectively selected 392 asymptomatic AS patients. RVEF, left ventricular ejection fraction (LVEF) and left atrial volumes (LAVs) were measured using 3DE datasets. We determined the association of those parameters, as well as of aortic valve replacement (AVR), and Charlson's comorbidity index with cardiac events. We also analyzed whether RVEF has incremental value over two-dimensional echocardiography (2DE) RV parameters. Results: During a median follow-up of 27 months, 57 patients developed cardiac events, and 68 patients received AVR. Univariate Cox proportional hazard analysis revealed that RVEF was associated with cardiac events (p < 0.001). Multivariate analysis revealed that RVEF was significantly associated with cardiac events (p < 0.001) even after adjusting for AVR, Charlson's comorbidity index, LVEF, LAV, E/e', and indexed aortic valve area (iAVA). An incremental value of RVEF over left heart parameters was also demonstrated using a nested regression model. Classification and regression-tree analysis selected RVEF first with a cut-off value of 41%. RVEF had incremental value over iAVA, LVEF, and 2DE conventional RV parameters for its association with future outcomes. Conclusions: 3DE RVEF had significant prognostic value even after adjusting for comorbidities, left heart parameters, and conventional 2DE RV parameters in asymptomatic aortic stenosis.

Asymptomatic aortic stenosis in a geriatric population. The role of frailty and comorbidity in mortality.

INTRODUCTION AND OBJECTIVES: The prognosis of asymptomatic severe aortic stenosis (AS) has not been widely documented in elderly patients who are frequently frail and have comorbidities. We sought to analyze the factors that influence early mortality in geriatric patients with asymptomatic severe AS. METHODS: This ambispective cohort study included 104 patients aged 70 years or older with asymptomatic severe AS. Epidemiological, geriatric, clinical and echocardiographic variables were collected and compared between frail and nonfrail patients. During follow-up, the time from diagnosis to mortality and the causes of death were recorded. RESULTS: Overall, 59.6% of the patients were frail. During follow-up, 69.4% of the frail patients died, with a median time to mortality of 2.52 years (95%CI, 1.36-3.69). The overall 1-year survival rate in frail patients was 76%. On multivariate analysis, age (HR, 2.47; 95%CI, 1.00-6.12), a Charlson comorbidity index ≥ 5 (HR, 3.75; 95%CI, 1.47-9.52) and frailty (HR, 6.67; 95%CI, 1.43-9.52) were independently related to mortality. In total, 8.7% of the patients had a Charlson comorbidity index ≥ 5, and all these patients died during follow-up, with a median survival of 1.01 years (95%CI, 0.36-1.67). The area under the receiver operating characteristic curve of the Charlson index was 0.739 (95%CI, 0.646-0.832). In this population, values ≥ 5 showed high specificity (100%) but low sensitivity. CONCLUSIONS: A high prevalence of frailty was present in geriatric patients with asymptomatic severe AS. Age, a Charlson index ≥ 5 and frailty were independent factors for mortality, conferring an unfavorable short-term prognosis.

Basal longitudinal strain predicts future aortic valve replacement in asymptomatic patients with aortic stenosis.

AIMS: To evaluate the prognostic value of global longitudinal strain (GLS) and basal longitudinal strain (BLS) with the knowledge of coexisting coronary pathology evaluated by multi-detector computed tomography (MDCT) coronary angiography. BACKGROUND: GLS and BLS are both sensitive markers of myocardial dysfunction and predictors of outcome in asymptomatic aortic stenosis. Aortic stenosis and ischaemic heart disease share risk factors and longitudinal function can be severely reduced in both conditions, why some of the previous findings of impaired regional longitudinal function in asymptomatic aortic stenosis could in fact be explained by silent ischaemic heart disease. METHODS AND RESULTS: Prospective follow-up of 104 asymptomatic patients with moderate-severe aortic stenosis defined as an aortic valve area <1.5 cm(2). Patients underwent a thorough clinical work-up, advanced echocardiographic analysis and coronary angiography by MDCT. The combined endpoint was indication for aortic valve replacement (AVR) and sudden cardiac death. During a median follow-up of 2.3 years (interquartile range 1.7-3.6) 43 patients (41%) met the endpoint of indication for AVR. The basal (13.4 ± 3.1% vs. 15.7 ± 3.1%) and mid-ventricular segments (14.9 ± 2.7% vs. 16.2 ± 2.9%) were significantly reduced, but with sparing of the apical segments, in patients who later underwent AVR. In various multivariable Cox regression models, including only BLS, but not GLS, remained an independent predictor of AVR. CONCLUSION: In contrast to GLS, reduced BLS is a significant predictor of future AVR in asymptomatic patients with aortic stenosis, independently of clinical characteristics, conventional echocardiographic measures, and coronary pathology.

Asymptomatic severe aortic stenosis with normal left ventricular function - A review.

Aortic stenosis (AS) is one of the commonest forms of acquired valvular heart disease. Aortic valve replacement (AVR) is the treatment of choice for symptomatic severe AS. Conservative management is usually advocated for asymptomatic severe AS. But there are data on predictors to identify subsets of asymptomatic AS patients at high risk of cardiac events in whom early surgical intervention is warranted. Non-invasive tests like exercise stress test, exercise echocardiography will help us to identify those who are at high risk of developing early symptoms due to LV dysfunction and also those at high risk of sudden death. In this article, an attempt is made to review the literature on this subset of asymptomatic severe AS to help clinicians to decide regarding the need for early aortic valve replacement in them.

Estenosis aórtica grave asintomática en la población geriátrica: papel de la fragilidad y la comorbilidad en la mortalidad / Asymptomatic aortic stenosis in a geriatric population. The role of frailty and comorbidity in mortality

Introducción y objetivos El pronóstico de la estenosis aórtica (EAo) grave asintomática en la población anciana, que a menudo asocia fragilidad y comorbilidades no ha sido estudiado. Se propuso analizar qué factores podrían influir en la mortalidad precoz esta población. Métodos Estudio ambispectivo de cohortes en 104 pacientes con edad ≥ 70 años y EAo grave asintomática. Se recogieron variables epidemiológicas, geriátricas, clínicas y ecocardiográficas y se compararon entre pacientes frágiles y no frágiles. Durante el seguimiento se recogió el tiempo desde el diagnóstico hasta la mortalidad. Resultados El 59,6% de los pacientes eran frágiles. El 69,4% de los pacientes frágiles fallecieron, con una mediana de supervivencia de 2,52 años (IC95%, 1,36-3,69). La tasa de supervivencia global al año en estos sujetos fue del 76%. En el análisis multivariante la edad (HR=2,47; IC95%, 1,00-6,12), el índice de Charlson ≥ 5 (HR=3,75; IC95%, 1,47-9,52) y la fragilidad (HR=6,67; IC95%, 1,43-9,52) se asociaron independientemente a la mortalidad. Un 8,7% de los pacientes presentaron un índice de Charlson ≥ 5 y tuvieron una mediana de supervivencia de 1,01 años (IC95%, 0,36-1,67). El área bajo la curva receiver operating characteristic del índice de Charlson fue 0,739 (IC95%, 0,646-0,832). Los valores ≥ 5 mostraron una elevada especificidad (100%) pero baja sensibilidad. Conclusiones Existe una elevada prevalencia de fragilidad en pacientes ancianos con EAo grave asintomáticos. La edad, un índice de Charlson ≥ 5 y la fragilidad son marcadores independientes de mortalidad, asociando un pronóstico desfavorable a corto plazo. (AU)

Introduction and objectives The prognosis of asymptomatic severe aortic stenosis (AS) has not been widely documented in elderly patients who are frequently frail and have comorbidities. We sought to analyze the factors that influence early mortality in geriatric patients with asymptomatic severe AS. Methods This ambispective cohort study included 104 patients aged 70 years or older with asymptomatic severe AS. Epidemiological, geriatric, clinical and echocardiographic variables were collected and compared between frail and nonfrail patients. During follow-up, the time from diagnosis to mortality and the causes of death were recorded. Results Overall, 59.6% of the patients were frail. During follow-up, 69.4% of the frail patients died, with a median time to mortality of 2.52 years (95%CI, 1.36-3.69). The overall 1-year survival rate in frail patients was 76%. On multivariate analysis, age (HR, 2.47; 95%CI, 1.00-6.12), a Charlson comorbidity index ≥ 5 (HR, 3.75; 95%CI, 1.47-9.52) and frailty (HR, 6.67; 95%CI, 1.43-9.52) were independently related to mortality. In total, 8.7% of the patients had a Charlson comorbidity index ≥ 5, and all these patients died during follow-up, with a median survival of 1.01 years (95%CI, 0.36-1.67). The area under the receiver operating characteristic curve of the Charlson index was 0.739 (95%CI, 0.646-0.832). In this population, values ≥ 5 showed high specificity (100%) but low sensitivity. Conclusions A high prevalence of frailty was present in geriatric patients with asymptomatic severe AS. Age, a Charlson index ≥ 5 and frailty were independent factors for mortality, conferring an unfavorable short-term prognosis. (AU)

The value of cardiopulmonary exercise testing in individuals with apparently asymptomatic severe aortic stenosis: a pilot study.

BACKGROUND: Risk stratification in asymptomatic patients with severe aortic stenosis (AS) is based on exercise test results. However, differentiating between pathological and physiological breathlessness during exercise is sometimes challenging. Cardiopulmonary exercise testing (CPET) may improve quantification of cardiopulmonary exercise capacity in patients with valve diseases. AIMS: To assess the ability of CPET to detect abnormal responses to exercise and a clinical endpoint (occurrence of European Society of Cardiology guidelines surgical class I triggers). METHODS: Forty-three consecutive patients (mean age 69±13 years; 31 men) with no reported symptoms and severe AS (aortic valve surface area<1 cm2 or indexed aortic valve surface area ≤0.6 cm2/m2) prospectively underwent symptom-limited CPET. RESULTS: Twelve (28%) patients had an abnormal exercise test (AET) with symptoms (abnormal dyspnoea n=11; angina n=1). Both VE/VCO2 slope>34 (hazard ratio [HR]=5.76, 95% confidence interval [CI] 1.086-30.587; P=0.04) and peak VO2≤14 mL/kg/min (HR 6.01, 95% CI 1.153-31.275; P=0.03) were independently associated with an AET. Furthermore, VE/VCO2 slope>34 (HR 3.681, 95% CI 1.318-10.286; P=0.013) and peak VO2≤14 mL/kg/min (HR 3.058, 95% CI 1.074-8.713; P=0.036) were independent predictors of reaching the clinical endpoint. CONCLUSIONS: Cardiopulmonary exercise testing is a useful tool for characterizing breathlessness during an exercise test in apparently asymptomatic patients with AS. Peak VO2≤14 mL/kg/min and VE/VCO2 slope>34 were associated with an AET and the occurrence of European Society of Cardiology guideline surgical class I triggers.

Actualización sobre el tratamiento quirúrgico de la estenosis aórtica asintomática / Update on surgical treatment of asymptomatic aortic stenosis

Aortic stenosis is becoming one of the most common diagnoses in cardiology in Western countries. A high percentage of patients with severe aortic stenosis remains asymptomatic, and management is not clearly established. In this article, we review the natural history of such patients and those factors with prognostic meaning identified in previous studies. Among them, positive exercise test, moderate to severe calcification in aortic valve, peak jet velocity > 4 m/s, left ventricular hypertrophy, left ventricular dysfunction and high values of natriuretic peptides (BNP) have been described as markers of poor prognosis in asymptomatic patients. These tests predict symptom-free survival and cardiovascular death. Sudden death is a fatal complication of aortic stenosis and congenital aortic stenosis is a cause of sudden death in young athletes. Its incidence is estimated in, approximately, 0.12-1% per year. Due to its low incidence, there are not studies for identifying patients at risk in this particular subset of patients. Medical and surgical treatment in asymptomatic patients remains controversial. Because degenerative stenosis has been described as "atheroscleroticlike" process, statins had been proposed to halt its progression, although its usefulness is not clearly established. In this article we review current practice guidelines for surgical treatment in asymptomatic patients with severe aortic stenosis

La estenosis aórtica es una de las enfermedades cardíacas más frecuentes en los países occidentales. Un elevado porcentaje de pacientes que presentan estenosis grave permanecen asintomáticos. Sin embargo, la valoración de los pacientes asintomáticos no ha sido bien establecida. En este artículo revisamos la evolución natural de estos pacientes y los estudios que evaluaron diferentes factores de riesgo en su evolución. Una ergometría positiva, calcificaciones valvulares, pico flujo aórtico > 4 m/s, hipertrofia del ventrículo izquierdo, disfunción del ventrículo izquierdo y valores elevados de péptidos natriuréticos (BNP) han sido descritos como marcadores de mal pronóstico en pacientes asintomáticos. Estas pruebas predicen supervivencia libre de síntomas y muerte por causa cardiovascular. La muerte súbita es una complicación fatal de la estenosis aórtica y la estenosis aórtica congénita es causa de muerte súbita en deportistas jóvenes. Su incidencia se estima en 0.12% a 1% por año. Debido a su baja incidencia no existen estudios que permitan identificar factores de riesgo en estos pacientes. El tratamiento médico y quirúrgico en pacientes asintomáticos es controvertido. Debido a la relación de la estenosis degenerativa con la aterosclerosis, se propuso el tratamiento con estatinas, si bien en estos momentos su indicación es dudosa. Revisamos las guías de practica clínica para el tratamiento quirúrgico de pacientes asintomáticos con estenosis grave