Outcomes with moderate aortic stenosis and impaired left ventricular function: prelude to a randomized trial?

The natural history of severe, symptomatic aortic stenosis (AS) has been well characterized, with most studies demonstrating a mortality rate of 50% at 2 years once patients develop symptoms of left ventricular (LV) systolic dysfunction (1,2). This precipitous decline in survival forms of the basis of current American Heart Association/American College of Cardiology class I recommendations for aortic valve replacement (AVR) in patients with: severe, symptomatic AS; asymptomatic patients with severe AS and a LV ejection fraction <50%; and patients with severe AS undergoing other cardiac surgery (3). However, AS is a progressive disease with an observed reduction in aortic valve area of approximately 0.1 cm2 per year (4,5). As such, current guidelines also recommend AVR for patients with moderate AS undergoing other cardiac surgery (3). An extension of current guidelines thus follows—should AVR be considered for patients with moderate AS and impaired LV function