Tạp chí Tim mạch học Việt Nam

Article detail

Article detail description

Home
BÀI TỔNG QUAN Issue: Số 122 - 2026 TIM MẠCH CAN THIỆP

Timing of Aortic Valve Intervention in the TAVI Era: From Active Surveillance to Evidence-Based Early Intervention and Individualized Treatment

Published: September 28, 2026
Views: 108
DOI 10.58354/jvc.122.2026.1324

Abstract

Aortic stenosis is the most prevalent valvular heart disease among older adults and a major cause of heart failure, hospitalization and death. For decades, watchful waiting until symptom onset or left ventricular systolic dysfunction has been the standard strategy in most asymptomatic patients with severe aortic stenosis. The rapid evolution of transcatheter aortic valve implantation has substantially modified the risk-benefit balance of valve intervention. Recent randomized trials, including RECOVERY, AVATAR, EVOLVED and EARLY TAVR, suggest that early intervention can reduce heart failure or unplanned cardiovascular hospitalizations, whereas an overall mortality benefit remains uncertain. TAVR UNLOAD further raised the hypothesis of treating moderate aortic stenosis in patients with heart failure with reduced ejection fraction, but did not demonstrate clear superiority over surveillance and guideline-directed medical therapy. This review summarizes contemporary evidence on the optimal timing of aortic valve replacement, emphasizing multimodality imaging, biomarkers, myocardial damage, lifetime management and shared decision-making through a multidisciplinary Heart Team. A pragmatic algorithm for Vietnamese cardiovascular practice is proposed.

Keywords
Aortic Stenosis TAVI SAVR Early Intervention Myocardial Fibrosis

References

1.
Craig NJ, Prendergast B, Newby DE, Dweck MR. Timing of transcatheter aortic valve implantation in patients with aortic stenosis. EuroIntervention. 2026;22:530-544.
2.
Praz F, Borger MA, Lanz J, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2025;46:4635-4736.
3.
Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary. Circulation. 2021;143:e35-e71.
4.
Osnabrugge RL, Mylotte D, Head SJ, et al. Aortic stenosis in the elderly: disease prevalence and number of candidates for TAVR. J Am Coll Cardiol. 2013;62:1002-1012.
5.
Lindman BR, Sukul D, Dweck MR, et al. Evaluating medical therapy for calcific aortic stenosis: JACC State-of-the-Art Review. J Am Coll Cardiol. 2021;78:2354-2376.
6.
Ross J Jr, Braunwald E. Aortic stenosis. Circulation. 1968;38:61-67.
7.
Braunwald E. On the natural history of severe aortic stenosis. J Am Coll Cardiol. 1990;15:1018-1020.
8.
Lancellotti P, Magne J, Dulgheru R, et al. Outcomes of patients with asymptomatic aortic stenosis followed up in heart valve clinics. JAMA Cardiol. 2018;3:1060-1068.
9.
Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis. Circulation. 1997;95:2262-2270.
10.
Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med. 2000;343:611-617.
11.
Bach DS, Siao D, Girard SE, et al. Evaluation of patients with severe symptomatic aortic stenosis who do not undergo AVR. Circ Cardiovasc Qual Outcomes. 2009;2:533-539.
12.
Kelly TA, Rothbart RM, Cooper CM, et al. Outcome of asymptomatic and symptomatic patients with valvular aortic stenosis. Am J Cardiol. 1988;61:123-130.
13.
Bouma BJ, van den Brink RBA, van der Meulen JHP, et al. To operate or not on elderly patients with aortic stenosis. Heart. 1999;82:143-148.
14.
Genereux P, Stone GW, O’Gara PT, et al. Transcatheter aortic-valve replacement for asymptomatic severe aortic stenosis. N Engl J Med. 2025;392:217-227.
15.
Loganath K, Treibel TA, Musa TA, et al. Early intervention in patients with asymptomatic severe aortic stenosis and myocardial fibrosis: the EVOLVED randomized clinical trial. JAMA. 2024;332:1987-1997.
16.
Kang DH, Park SJ, Lee SA, et al. Early surgery or conservative care for asymptomatic aortic stenosis. N Engl J Med. 2020;382:111-119.
17.
Kang DH, Park SJ, Kim GY, et al. Early surgery or conservative care for asymptomatic aortic stenosis at 10 years. N Engl J Med. 2026;394:1167-1174.
18.
Banovic M, Putnik S, Penicka M, et al. Aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis: the AVATAR trial. Circulation. 2022;145:648-658.
19.
Banovic M, Athithan L, McCann GP. Aortic valve replacement versus conservative treatment in asymptomatic severe aortic stenosis: extended follow-up of the AVATAR trial. Eur Heart J. 2024;45:4526-4536.
20.
Van Mieghem NM, Elmariah S, Spitzer E, et al. Transcatheter aortic valve replacement in patients with systolic heart failure and moderate aortic stenosis: TAVR UNLOAD. J Am Coll Cardiol. 2025;85:1-13.
21.
Clavel MA, Messika-Zeitoun D, Pibarot P, et al. The complex nature of discordant severe calcified aortic valve disease grading. J Am Coll Cardiol. 2013;62:2329-2338.
22.
Pibarot P, Dumesnil JG. Low-flow, low-gradient aortic stenosis with normal and depressed LVEF. J Am Coll Cardiol. 2012;60:1845-1853.
23.
Nishimura RA, Grantham JA, Connolly HM, et al. Low-output, low-gradient aortic stenosis in patients with depressed LVEF. Circulation. 2002;106:809-813.
24.
Monin JL, Quere JP, Monchi M, et al. Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome. Circulation. 2003;108:319-324.
25.
Clavel MA, Ennezat PV, Marechaux S, et al. Stress echocardiography to assess AS severity and contractile reserve. J Am Coll Cardiol. 2013;62:2320-2328.
26.
Baumgartner H, Hung J, Bermejo J, et al. Recommendations on echocardiographic assessment of aortic stenosis. Eur Heart J Cardiovasc Imaging. 2017;18:254-275.
27.
Pibarot P, Clavel MA. Management of paradoxical low-flow, low-gradient aortic stenosis. J Am Coll Cardiol. 2015;65:67-71.
28.
Dweck MR, Boon NA, Newby DE. Calcific aortic stenosis: a disease of the valve and myocardium. J Am Coll Cardiol. 2012;60:1854-1863.
29.
Dweck MR, Joshi S, Murigu T, et al. Midwall fibrosis is an independent predictor of mortality in patients with aortic stenosis. J Am Coll Cardiol. 2011;58:1271-1279.
30.
Musa TA, Treibel TA, Vassiliou VS, et al. Myocardial scar and mortality in severe aortic stenosis. Circulation. 2018;138:1935-1947.
31.
Thornton GD, Vassiliou VS, Musa TA, et al. Myocardial scar and remodelling predict long-term mortality in severe aortic stenosis beyond 10 years. Eur Heart J. 2024;45:2019-2022.
32.
Treibel TA, Kozor R, Schofield R, et al. Reverse myocardial remodeling following valve replacement in aortic stenosis. J Am Coll Cardiol. 2018;71:860-871.
33.
Weidemann F, Herrmann S, Stork S, et al. Impact of myocardial fibrosis in severe aortic stenosis. Circulation. 2009;120:577-584.
34.
Azevedo CF, Nigri M, Higuchi ML, et al. Prognostic significance of myocardial fibrosis in severe aortic valve disease. J Am Coll Cardiol. 2010;56:278-287.
35.
Singh A, Chan DCS, Kanagala P, et al. Short-term adverse remodeling progression in asymptomatic aortic stenosis. Eur Radiol. 2021;31:3923-3930.
36.
Chin CWL, Everett RJ, Kwiecinski J, et al. Myocardial fibrosis and cardiac decompensation in aortic stenosis. JACC Cardiovasc Imaging. 2017;10:1320-1333.
37.
Everett RJ, Tastet L, Clavel MA, et al. Progression of hypertrophy and myocardial fibrosis in aortic stenosis. Circ Cardiovasc Imaging. 2018;11:e007451.
38.
Ng ACT, Delgado V, Bertini M, et al. Alterations in multidirectional myocardial functions in patients with aortic stenosis. J Am Soc Echocardiogr. 2011;24:1238-1247.
39.
Vollema EM, Sugimoto T, Shen M, et al. Association of left ventricular global longitudinal strain with asymptomatic severe aortic stenosis outcomes. JAMA Cardiol. 2018;3:839-847.
40.
Zito C, Salvia J, Cusma-Piccione M, et al. Prognostic significance of LV global longitudinal strain in asymptomatic severe aortic stenosis. J Am Soc Echocardiogr. 2011;24:766-772.
41.
Levy F, Laurent M, Monin JL, et al. Aortic valve replacement for low-flow/low-gradient aortic stenosis: operative risk and long-term outcome. Eur Heart J. 2008;29:767-774.
42.
Capoulade R, Magne J, Dulgheru R, et al. Prognostic value of plasma B-type natriuretic peptide levels after exercise in AS. Heart. 2014;100:1606-1612.
43.
Bergler-Klein J, Klaar U, Heger M, et al. Natriuretic peptides predict symptom-free survival and postoperative outcome in AS. Circulation. 2004;109:2302-2308.
44.
Clavel MA, Malouf J, Michelena HI, et al. B-type natriuretic peptide clinical activation in aortic stenosis. J Am Coll Cardiol. 2014;63:2016-2025.
45.
Chin CWL, Shah ASV, McAllister DA, et al. High-sensitivity troponin I concentrations are a marker of advanced hypertrophy and adverse outcomes in aortic stenosis. Eur Heart J. 2014;35:2312-2321.
46.
Ruparelia N, Prendergast BD. TAVI in aortic stenosis: from high-risk to low-risk patients. Heart. 2020;106:547-555.
47.
Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380:1695-1705.
48.
Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med. 2019;380:1706-1715.
49.
Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609-1620.
50.
Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187-2198.
51.
Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. 2014;370:1790-1798.
52.
Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter AVR in intermediate-risk patients. N Engl J Med. 2017;376:1321-1331.
53.
Thyregod HGH, Steinbruchel DA, Ihlemann N, et al. Transcatheter versus surgical AVR in lower-risk patients: NOTION trial. J Am Coll Cardiol. 2015;65:2184-2194.
54.
Jorgensen TH, Thyregod HGH, Ihlemann N, et al. Ten-year outcomes from the NOTION trial. Eur Heart J. 2024;45:1116-1126.
55.
Baron SJ, Arnold SV, Herrmann HC, et al. Impact of TAVR on health status in severe AS. J Am Coll Cardiol. 2017;69:2839-2850.
56.
Arnold SV, Baron SJ, Reynolds MR, et al. Health status after TAVR or surgical AVR in low-risk patients. J Am Coll Cardiol. 2020;76:1209-1221.
57.
Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2022;43:561-632.
58.
Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: population-based study. Lancet. 2006;368:1005-1011.
59.
Iung B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe. Eur Heart J. 2003;24:1231-1243.
60.
Iung B, Vahanian A. Epidemiology of acquired valvular heart disease. Can J Cardiol. 2014;30:962-970.
61.
Eveborn GW, Schirmer H, Heggelund G, et al. The evolving epidemiology of valvular aortic stenosis: Tromso Study. Heart. 2013;99:396-400.
62.
Stewart BF, Siscovick D, Lind BK, et al. Clinical factors associated with calcific aortic valve disease. J Am Coll Cardiol. 1997;29:630-634.
63.
Otto CM, Lind BK, Kitzman DW, et al. Association of aortic-valve sclerosis with cardiovascular mortality. N Engl J Med. 1999;341:142-147.
64.
Mohler ER 3rd, Gannon F, Reynolds C, et al. Bone formation and inflammation in cardiac valves. Circulation. 2001;103:1522-1528.
65.
New SEP, Aikawa E. Molecular imaging insights into early inflammatory stages of arterial and aortic valve calcification. Circ Res. 2011;108:1381-1391.
66.
Rajamannan NM, Evans FJ, Aikawa E, et al. Calcific aortic valve disease: not simply degenerative. Circulation. 2011;124:1783-1791.
67.
Cowell SJ, Newby DE, Prescott RJ, et al. A randomized trial of intensive lipid-lowering therapy in calcific AS. N Engl J Med. 2005;352:2389-2397.
68.
Rossebo AB, Pedersen TR, Boman K, et al. Intensive lipid lowering with simvastatin and ezetimibe in AS. N Engl J Med. 2008;359:1343-1356.
69.
Chan KL, Teo K, Dumesnil JG, et al. Effect of lipid lowering with rosuvastatin on progression of AS: ASTRONOMER trial. Circulation. 2010;121:306-314.
70.
Bohbot Y, de Meester de Ravenstein C, Chadha G, et al. Relationship between BNP and outcome in AS. J Am Coll Cardiol. 2019;74:1652-1663.
71.
Cioffi G, Faggiano P, Vizzardi E, et al. Prognostic effect of inappropriately high LV mass in asymptomatic severe AS. Heart. 2011;97:301-307.
72.
Généreux P, Pibarot P, Redfors B, et al. Staging classification of aortic stenosis based on extent of cardiac damage. Eur Heart J. 2017;38:3351-3358.
73.
Généreux P, Stone GW, Pibarot P, et al. Natural history, diagnostic approaches, and therapeutic strategies for patients with asymptomatic severe AS. J Am Coll Cardiol. 2016;67:2263-2288.
74.
Clavel MA, Burwash IG, Pibarot P. Cardiac imaging for assessing low-gradient severe AS. JACC Cardiovasc Imaging. 2017;10:185-202.
75.
Pawade TA, Doris MK, Bing R, et al. Effect of denosumab or alendronic acid on progression of AS: SALTIRE2. Circulation. 2021;143:2418-2427.
76.
Pawade TA, Newby DE, Dweck MR. Calcification in aortic stenosis: the skeleton key. J Am Coll Cardiol. 2015;66:561-577.
77.
Pawade T, Clavel MA, Tribouilloy C, et al. Computed tomography aortic valve calcium scoring in AS. Circ Cardiovasc Imaging. 2018;11:e007146.
78.
Clavel MA, Messika-Zeitoun D, Pibarot P, et al. Aortic valve calcification in AS: sex-specific thresholds. J Am Coll Cardiol. 2014;64:1202-1213.
79.
Messika-Zeitoun D, Aubry MC, Detaint D, et al. Evaluation and clinical implications of aortic valve calcification by CT. Circulation. 2004;110:356-362.
80.
Dweck MR, Jenkins WSA, Vesey AT, et al. 18F-sodium fluoride uptake is a marker of active calcification and disease progression in AS. Circ Cardiovasc Imaging. 2014;7:371-378.
81.
Dweck MR, Khaw HJ, Sng GKZ, et al. Aortic stenosis, atherosclerosis, and skeletal bone: is there a common link? J Am Coll Cardiol. 2013;61:522-532.
82.
Kwiecinski J, Dweck MR, Marsan NA, et al. PET imaging of inflammation and calcification in aortic stenosis. JACC Cardiovasc Imaging. 2020;13:1602-1615.
83.
Ribeiro HB, Webb JG, Makkar RR, et al. Predictive factors, management, and clinical outcomes of coronary obstruction following TAVI. J Am Coll Cardiol. 2013;62:1552-1562.
84.
Tarantini G, Nai Fovino L, Scotti A, et al. Coronary access after TAVI: challenges and strategies. JACC Cardiovasc Interv. 2020;13:2521-2535.
85.
Tang GHL, Zaid S, Fuchs A, et al. Alignment of transcatheter aortic-valve neo-commissures and coronary arteries. JACC Cardiovasc Interv. 2020;13:1030-1042.
86.
Yoon SH, Whisenant BK, Bleiziffer S, et al. Outcomes of TAVR for bicuspid aortic valve stenosis. J Am Coll Cardiol. 2017;69:2579-2589.
87.
Makkar RR, Yoon SH, Leon MB, et al. Association between TAVR for bicuspid vs tricuspid AS and outcomes. JAMA. 2019;321:2193-2202.
88.
Sondergaard L, De Backer O, Kofoed KF, et al. Natural history of subclinical leaflet thrombosis affecting motion in bioprosthetic aortic valves. Eur Heart J. 2017;38:2201-2207.
89.
Makkar RR, Fontana G, Jilaihawi H, et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med. 2015;373:2015-2024.
90.
Dangas GD, Tijssen JGP, Wohrle J, et al. A controlled trial of rivaroxaban after TAVR. N Engl J Med. 2020;382:120-129.
91.
Collet JP, Van Belle E, Thiele H, et al. Apixaban versus standard of care after TAVI: ATLANTIS. Eur Heart J. 2022;43:2783-2797.
92.
Nijenhuis VJ, Brouwer J, Delewi R, et al. Anticoagulation with or without clopidogrel after TAVI. N Engl J Med. 2020;382:1696-1707.
93.
Brouwer J, Nijenhuis VJ, Delewi R, et al. Aspirin with or without clopidogrel after TAVI. N Engl J Med. 2020;383:1447-1457.
94.
Van Belle E, Vincent F, Labreuche J, et al. Balloon-expandable versus self-expandable TAVR devices in bicuspid anatomy. JACC Cardiovasc Interv. 2020;13:1440-1451.
95.
De Backer O, Dangas GD, Jilaihawi H, et al. Reduced leaflet motion after TAVR. N Engl J Med. 2020;382:130-139.
96.
Siontis GCM, Overtchouk P, Cahill TJ, et al. TAVR vs SAVR for AS: meta-analysis of randomized trials. Eur Heart J. 2019;40:3143-3153.
97.
Kolte D, Khera S, Sardar MR, et al. Thirty-day readmissions after TAVR in the United States. Circ Cardiovasc Interv. 2017;10:e004472.
98.
Lauck SB, Baron SJ, Irish W, et al. Temporal changes in TAVI outcomes: contemporary registry data. JACC Cardiovasc Interv. 2020;13:403-414.
99.
Arnold SV, Spertus JA, Vemulapalli S, et al. Association of patient-reported health status with long-term mortality after TAVR. Circ Cardiovasc Qual Outcomes. 2015;8:590-596.
100.
Lindman BR, Dweck MR, Lancellotti P, et al. Management of asymptomatic severe AS: evolving evidence and clinical challenges. J Am Coll Cardiol. 2020;75:1762-1776.
101.
Généreux P, Schwartz A, Oldemeyer JB, et al. Randomized evaluation of TAVR compared to surveillance for asymptomatic severe AS: trial design. Am Heart J. 2021;232:188-197.
102.
ClinicalTrials.gov. Early Valve Replacement in Severe Asymptomatic Aortic Stenosis Study (EASY-AS). NCT04204915.
103.
ClinicalTrials.gov. Danish National Randomized Study on Early Aortic Valve Replacement in Patients With Asymptomatic Severe Aortic Stenosis (DANAVR). NCT03972644.
104.
ClinicalTrials.gov. Management of Moderate Aortic Stenosis by Clinical Surveillance or TAVR (PROGRESS). NCT04889872.
105.
ClinicalTrials.gov. Evolut EXPAND TAVR II Pivotal Trial. NCT05149755.

Tác giả

Phạm Mạnh Hùng: Trường Đại học Y Hà Nội;
Timing of Aortic Valve Intervention in the TAVI Era: From Active Surveillance to Evidence-Based Early Intervention and Individualized Treatment

Files

PDF
Article Views108
Document Views0
Downloads13
Section BÀI TỔNG QUAN
Issue Số 122 - 2026
Category TIM MẠCH CAN THIỆP
Pages 5-21
Copyright Holder 2026 Tạp chí Tim mạch học Việt Nam

Related articles section label

Related articles

Related articles category hint

More articles

Factors Associated with Early In-Hospital Outcomes of Primary Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction and Type 2 Diabetes Mellitus

Objectives: To investigate factors associated with early in-hospital outcomes of primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) and type 2 diabetes mellitus (T2DM). Me...

Chi tiết bài báo
PDF
DOI: 10.58354/jvc.122.2026.1328
112
Nguyễn Duy Tùng; Nguyễn Kỳ Chinh; Vũ Mạnh Tân