C’est LAVi

Calcific degenerative aortic valve stenosis (AS) is the most common acquired form of heart valve disease that afflicts the elderly population1 and usually comes to attention when an echocardiogram is ordered to evaluate a systolic murmur in an older subject. As is evident to anyone practicing cardiology these days, the advent of transcatheter aortic valve replacement has focused much attention on the evaluation and optimal treatment of patients with AS. AS often has a long latency period in which symptoms are absent, and, importantly, sudden unexpected cardiac death is rare.2,3 With symptom onset, survival is markedly reduced without intervention.4–6 For symptomatic patients with severe AS and normal flow-high gradient characteristics and normal left ventricular ejection fraction (LVEF) (stage D1), aortic valve replacement (AVR) is a class 1 indication. Similarly, for asymptomatic patients with severe AS and LVEF <50% not because of another cause (stage C2), AVR also is indicated.See Article by Christensen et al Among truly asymptomatic patients with severe AS and normal LVEF, the management can be much more challenging. In this subset of patients, a strategy of watchful waiting or active surveillance is most often used until symptom onset occurs. When close clinical follow-up can be provided along with encouragement of prompt reporting of symptoms by the patient, AVR can be performed with low risk and good long-term results, and we now know that, approximately two thirds of patients will develop symptoms within 5 years.2 Thus, a balance must be struck between the low risk of sudden death during this watchful waiting period and the morbidity and mortality associated with AVR. In this connection, the cautionary words of Dr Braunwald7 remain as true today as they were a quarter century ago: “The most common cause of sudden death …