The following are key points to remember from a review on aortic stenosis (AS), heart failure (HF), and aortic valve replacement (AVR):

1. AS is responsible for the development of HF that is mediated both by AS-associated chronic pressure afterload and subsequent unfavorable cardiac remodeling that includes left ventricular (LV) hypertrophy with impaired coronary microvascular function and eventual myocardial fibrosis.
2. Evidence of LV impairment caused by AS can be detected using echocardiographic global longitudinal strain imaging for occult myocardial dysfunction, and cardiac magnetic resonance imaging for evidence of focal myocardial fibrosis (using late gadolinium enhancement) or diffuse interstitial myocardial fibrosis (using T1 mapping and myocardial extracellular volume quantitation).
3. Serum biomarkers including natriuretic peptides (B-type natriuretic peptide [BNP] and N-terminal pro-BNP) and troponin can serve as surrogate markers to help identify patients with asymptomatic AS or moderate AS who might benefit from earlier intervention.
4. Both patient-related and procedure-related factors can contribute to HF among patients who undergo aortic valve replacement (AVR) for AS.
   • Patient-related factors include diabetes, which worsens LV remodeling and affects both systolic and diastolic LV function; cardiac amyloidosis; atrial fibrillation; concomitant valvular heart disease including mitral regurgitation and/or tricuspid regurgitation; and concomitant coronary artery disease, which can exacerbate myocardial ischemia and therefore LV dysfunction.
   • Procedure-related factors include conduction disturbances and permanent pacemaker implantation with resulting left bundle branch block; abnormalities in valve performance including paravalvular leak after transcatheter aortic valve replacement (TAVR) and moderate or severe prosthesis-patient mismatch, more common after surgical aortic valve replacement (SAVR); and myocardial injury after either SAVR or TAVR.
5. Mid-term data suggest that HF hospitalization is more common after SAVR than after TAVR, although long-term data still are outstanding.
6. Guidelines on the management of patients with heart valve disease do not include recommendations specific to the treatment of HF before or after AVR for AS. Published data suggest that treatment with renin-angiotensin-system inhibitor therapy (but not beta-adrenergic antagonist therapy) is associated with decreased all-cause mortality and HF hospitalization.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease

Keywords: Aortic Valve Stenosis, Heart Failure, Transcatheter Aortic Valve Replacement

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