Aortic stenosis (AS) affects about 12% of people aged ≥75 years. Accumulating evidence on the prognostic importance of cardiac damage in patients with asymptomatic and less than severe AS supports the proposition of advancing aortic valve replacement (AVR) to earlier disease stages. Potential benefits of earlier treatment, including prevention of cardiac damage progression and reduced cardiovascular hospitalizations, need to be balanced against the earlier procedural risk and subsequent lifetime management after AVR. Two small, randomized trials indicate that early surgical AVR may improve survival in patients with asymptomatic severe AS, and observational data suggest that AVR may reduce mortality even in patients with moderate AS. A clear understanding of the pathophysiology of cardiac damage secondary to AS is needed to develop strategies to select patients for earlier AVR. Noninvasive imaging can detect early cardiac damage, and indices such as fibrosis, global longitudinal strain, and myocardial work index have potential use to guide stratification of patients for earlier AVR. Ongoing randomized trials are investigating the safety and efficacy of AVR for patients with asymptomatic severe AS and those with moderate AS who have symptoms/evidence of cardiac damage. Pathophysiological considerations and accumulating evidence from clinical studies that support earlier timing of AVR for AS will need to be corroborated by the results of these trials. This review aims to evaluate the evidence for earlier AVR, discuss strategies to guide stratification of patients who may benefit from this approach, highlight the relevant ongoing randomized trials, and consider the consequences of earlier intervention.

中文翻译：

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主动脉瓣干预治疗主动脉瓣狭窄的时间。


主动脉瓣狭窄 （AS） 影响约 12% 的 ≥75 岁人群。关于无症状和轻重 AS 患者心脏损伤预后重要性的累积证据支持将主动脉瓣置换术 （AVR） 提前到早期疾病阶段的主张。早期治疗的潜在益处，包括预防心脏损伤进展和减少心血管住院治疗，需要与 AVR 后的早期手术风险和随后的终生管理相平衡。两项小型随机试验表明，早期手术 AVR 可能会提高无症状重度 AS 患者的生存率，观察性数据表明，AVR 可能会降低中度 AS 患者的死亡率。需要清楚地了解 AS 继发性心脏损伤的病理生理学，以制定选择早期 AVR 患者的策略。无创影像学检查可以检测早期心脏损伤，纤维化、整体纵向应变和心肌功指数等指标可能用于指导早期 AVR 患者的分层。正在进行的随机试验正在调查 AVR 对无症状重度 AS 患者和有心脏损伤症状/证据的中度 AS 患者的安全性和有效性。病理生理学考虑和临床研究中支持早期 AVR 治疗 AS 的证据表明，这些试验的结果需要得到证实。本综述旨在评估早期 AVR 的证据，讨论指导可能从这种方法中受益的患者分层的策略，强调相关的正在进行的随机试验，并考虑早期干预的后果。