In a finding that challenges conventional thinking on when people with failing heart valves but no symptoms should get surgery, a new study suggests these patients would fare far better if they had their valves replaced right away with a minimally invasive procedure.

The results, published this week in the New England Journal of Medicine, could change the way severe aortic stenosis, a narrowing of the valve that controls blood flow from the heart, is treated. Until now, many doctors have preferred a watch-and-wait approach with these patients.

What did the researchers discover about early surgery for these folks?

Replacing people’s heart valves before they experienced any side effects or symptoms halved their risk of being hospitalized for heart problems for at least two years, the trial found.

More specifically, death occurred in 8.4% of the patients assigned to early surgery and in 9.2% of the patients on clinical surveillance, while stroke occurred in 4.2% and 6.7%, respectively, and unplanned hospitalization for cardiovascular causes occurred in 20.9% and 41.7%, respectively.

“Among patients with asymptomatic severe aortic stenosis, a strategy of early [surgery] was superior to clinical surveillance in reducing the incidence of death, stroke or unplanned hospitalization for cardiovascular causes,” the researchers concluded in their study.

Not only that, but most patients who were put on a more conservative treatment plan ended up needing surgery anyway: Roughly 70 percent of them developed symptoms and needed to have their valves replaced within two years, suggesting the disease worsens more rapidly than believed.

“You may be able to at least prevent that progression and perhaps improve patient outcomes by treating earlier,” Dr. Gregg Stone, a professor of medicine at the Icahn School of Medicine at Mount Sinai in New York City who wasn’t involved in the trial, told the New York Times. The findings, he said, “will have a major effect on practice.”

In the past, cardiologists have been wary of replacing valves partly because that would have required open-heart surgery, which carries its own significant risks, the Times reported.

But the emergence of a less invasive surgery offered another option. In that surgery, called transcatheter aortic valve replacement (TAVR), cardiologists move a replacement valve through a patient’s groin and thread it all the way to the heart.

For the new trial, researchers led by Dr. Philippe Généreux, a director of the structural heart program at Morristown Medical Center in New Jersey, recruited about 900 people with severe aortic stenosis who could still pass a treadmill stress test. Half of them were randomly chosen to get early surgery, while the other half were given the standard wait-and-see treatment.

More than 2 in 5 of the wait-and-see patients ended up being unexpectedly hospitalized with heart problems, compared with only 1 in 5 of the surgical patients.

Doctors said that more studies were needed on the durability of replacement valves and the best approach for younger patients.

“Cardiologists will be having very different conversations with patients now,” Dr. Toby Rogers, an interventional cardiologist at MedStar Washington Hospital Center who consults for the valve maker that sponsored the trial but was not involved in running it, told the Times. “Going earlier avoids bad things happening, especially ending up in the hospital.”

More information

Johns Hopkins has more on TAVR.

SOURCES: New England Journal of Medicine, Oct. 28, 2024; New York Times

Source: HealthDay

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