‘Wait and see approach’ to heart valve disease under scrutiny

Take action or wait and see? That’s been the longstanding question when it comes to people with failing heart valves experiencing few early symptoms.
Now, the “wait and see” approach with regular checkups is coming into question with results of a new study published this fall in The New England Journal of Medicine. Results show early surgical intervention may be better after all.
Pittsburgh-based Allegheny General Hospital (AGH) was one of the top enrolling medical centers in the trial, with Dr. Stephen Bailey, cardiothoracic surgeon and Chair of AHN Cardiovascular Institute, serving as the site’s principal investigator. Key findings show early minimally invasive surgery to replace failing heart valves can significantly reduce hospitalization risk for symptom-free patients.
“The findings of this study are extremely important, but not completely surprising,” says Bailey. “The trial demonstrates there may be a greater benefit in treating severe aortic stenosis earlier. In some cases, this would be even before patients begin to experience symptoms. This is the first randomized-controlled prospective clinical trial demonstrating the benefit, which makes it quite an important finding that could potentially change how we tailor treatment plans and their timing for our patients.”
Results like these could change the way doctors treat severe aortic stenosis, a narrowing of the valve that controls blood flow from the heart. The disease has a prognosis worse than that of most types of cancer and affects more than 3% of people ages 65 and older. Study results show that replacing heart valves even in patients not yet experiencing symptoms appeared to have reduced their risk of unexpected hospitalization for heart problems over at least two years by as much as 50%. By comparison, patients who did not have early intervention surgery and who were instead given the “wait and see” approach to care were far more likely to need surgery anyway. Almost 70% of those patients developed symptoms and required heart valve replacement within two years.
Part of the change in thinking is due to improved surgery techniques. Replacing faulty heart valves used to require open-heart surgery, which can be risky and lead to other complications. Now, a minimally invasive technique called transcatheter aortic valve replacement (TAVR) allows surgeons to insert a replacement heart valve through veins in the groin and thread it all the way to the heart. Bailey says TAVR has revolutionized treatment because it provides an alternative for patients who may not be good candidates for surgery.
“It’s extremely important to see a cardiovascular specialist who can determine the best option for you – sometimes the less invasive option is best, and sometimes the more traditional surgery is actually safer or better for the specific patient in the long-term. Recommended interventions truly depend on each patient and their specific circumstances.”
The study recruited about 900 people aged 65 or older with severe aortic stenosis who could still pass a treadmill stress test. Half of the participants got the “wait and see” approach while the other half underwent early surgery. Only 1 in 5 of the surgical patients wound up unexpectedly hospitalized for heart issues as compared to 2 in 5 of the hands-off group.
While early intervention may not be the path forward for every patient, Bailey thinks the findings of this clinical trial could bring about important conversations.
“It will likely foster access for patients with severe or near severe aortic stenosis to seek care advice and counsel with aortic valve specialists and cardiovascular experts in treating the condition,” Bailey says. “This specialized care team can then weigh in on the specific risks and benefits of earlier treatment for each unique patient. By introducing aortic valve experts into the patient journey sooner, some of the decision-making responsibilities are undoubtedly taken off other care providers who may be unfamiliar with recent changes in the field.”
The most common symptoms of aortic stenosis are shortness of breath and exercise intolerance. Any patient with these symptoms should be evaluated for valvular heart disease, often with an echocardiogram.
“We tend to make excuses for changes in our energy levels and fitness as we get older – blaming weight gain, other health issues, or just the aging process,” Bailey adds. “But it’s important to listen to your body. If something doesn’t feel right, get it checked out. I see this a lot in my clinic; patients often downplay their symptoms, maybe slowing down to avoid things that trigger them, and convince themselves they’re fine. This new study will help us make clearer, more confident decisions about treating severe aortic stenosis.”