Researchers Recommend Replacing Heart Valves That Are Failing, Even If No Symptoms Experienced

For decades, doctors have called for a “wait and see” approach for treatment of failing heart valves, thinking that transcatheter aortic valve replacement (TAVR) surgery was too risky. However, new research calls that practice into question, suggesting that it may be better to replace failing heart valves as early as possible.

In findings published this week in the New England Journal of Medicine, researchers from Morristown Medical Center in New Jersey indicate that patients who undergo heart valve replacement instead of having doctors monitor their condition for several years, face a lower risk of suffering cardiovascular side effects like stroke. In addition, the study found that the risk of hospitalization was cut nearly in half with the use of transcatheter aortic valve replacement when compared to those in the surveillance group.

TAVR is a procedure where the heart valve is replaced by threading it through an artery in the leg instead of via open chest surgery. It places the valve directly over the damaged aortic valve in a less invasive procedure, which is why it is often favored by doctors.

However, instead of first looking to TAVR, doctors often use a watch-and-wait approach when treating people who suffer from asymptomatic severe aortic stenosis, or a severe narrowing of the heart valve that controls blood flow from the heart. The condition often has a worse outcome for patients than most cancers and roughly 3% of people over 65 years old will suffer from the condition.

Typically, physicians wait to conduct a TAVR or perform a minimally invasive heart valve replacement with a balloon threaded through the groin, instead of open heart surgery.

Current guidelines call for surveillance every six to 12 months before surgery is recommended, given the risk nature of the procedures. However, that may no longer be the best approach.

In the new study, a team led by Dr. Phillippe Généreux studied more than 900 patients with failing heart valves across 75 medical centers in the U.S. and Canada. Half were assigned to doctor surveillance and the other half were given an early TAVR surgery to replace the heart valve.

Overall, 27% of patients who had heart valve replacement surgery suffered side effects like a stroke or were hospitalized early. Comparatively, 45% of the surveillance group experienced those complications.

The death rate among surgical patients was 8% and among surveillance patients, it was 9%.

More so, only 4% of the surgical patients had a stroke, compared to 7% of the surveillance patients. Unplanned hospitalization rates were 21% in the TAVR surgery group and 42% in the surveillance group.

The researchers noted that 87% of patients assigned to the “wait and see” surveillance group ended up needing surgery to have a heart valve replacement anyway. They often had to undergo the surgery within two years. Researchers said this suggests the heart condition may get worse more quickly than was previously believed.

In the long run, patients who underwent valve replacement earlier were better off and faced a lower risk of cardiovascular side effects, hospitalization and death.

“Among patients with asymptomatic severe aortic stenosis, a strategy of early TAVR was superior to clinical surveillance in reducing the incidence of death, stroke, or unplanned hospitalization for cardiovascular causes,” wrote study authors.

Prior studies indicated heart valves used in the TAVR surgery may deteriorate more rapidly, especially among patients with kidney disease. More research is needed to examine the durability of the replacement heart valves, especially among patients who may be younger and will need to have the valves in place longer.

However, the approach for active surveillance among heart patients may not be the best course of action, Généreux’s team determined. They recommended doctors weigh the risks and benefits of early TAVR surgery for patients with failing heart valves.