Monitoring

For asymptomatic patients, close follow-up is imperative. While symptoms generally do not occur unless the patient has severe AS, patients with moderate AS need to be questioned thoroughly about symptoms, as the patient may often attribute functional decline with progressive AS to other causes such as age. A large prospective study of asymptomatic patients with severe AS showed that at 5 years only 20% were free of cardiovascular death or aortic valve replacement (AVR).[84] It may be appropriate to perform an exercise test in asymptomatic patients with severe AS to assess symptoms and physiological response to exercise. Those who become symptomatic or who do not show an appropriate increase in blood pressure should probably be referred for surgery.[26]

Serial follow-up of asymptomatic patients found to have AS depends on the severity of stenosis.

The American College of Cardiology/American Heart Association (ACC/AHA) recommend the following timeframes for follow-up:[26]​ 

  • Mild stenosis: transthoracic echocardiogram (TTE) every 3 to 5 years

  • Moderate stenosis: TTE every 1 to 2 years

  • Severe stenosis (asymptomatic): TTE every 6 to 12 months.

The European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (ESC/EACS) guidelines place an emphasis on the importance of regular follow-up including TTE, the frequency of which depends on each individual.Those with severe AS should be followed up every 6 months. Younger patients with mild AS and no significant calcification may be followed up every 2-3 years.[44]

The National Institute for Health and Care Excellence (NICE) in the UK recommends following up as detailed below:[28]

  • Mild and moderate stenosis: TTE every 3 to 5 years

  • Severe stenosis: clinical review every 6 to 12 months (which should include TTE) if an intervention is suitable but not currently needed. NICE advises basing the frequency of review on the echocardiography findings and shared decision making with the patient.

Following AVR, patients should have a complete physical examination 2 to 4 weeks after hospital discharge, with attention to the presence or improvement of preoperative symptoms. A transthoracic echocardiogram should be performed as well to assess prosthetic valve function. In the absence of clinical deterioration, history and physical examination should be performed at least annually. Any change in clinical status should be evaluated with an echocardiogram, and patients with bioprosthetic valves should probably have an echocardiogram annually after 10 years even in the absence of symptoms to evaluate valve function.[26] While the echocardiographic assessment of transcatheter aortic valve replacement (TAVR) prostheses is similar to the assessment of surgically-placed valves, current recommendations call for more frequent evaluations in patients with these new devices (yearly).[59] Patients with paravalvular aortic regurgitation have a higher risk of mortality and should be followed even more closely.[52]

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