Aortic Valve Interventions in Asymptomatic Severe Aortic Stenosis: Who, Why, and When?

Symptomatic severe aortic stenosis has an extremely high risk of death, ranging from 60 to 90% at five years if left untreated. This has informed the recommendation for urgent intervention upon diagnosis, especially when symptoms develop. Asymptomatic severe aortic stenosis has a four-year mortality between 30 and 50% if left untreated, which is similar to some metastatic cancers. Conservative management for patients with severe asymptomatic aortic stenosis was previously advocated, likely owing to the relative invasiveness of surgical aortic valve replacement. The advent of low-risk transcatheter aortic valve implantation with good medium-term durability has prioritized the need for a paradigm shift in the treatment of asymptomatic severe aortic stenosis towards a more proactive strategy of early intervention to reduce significant adverse events. This article provides a state-of-the-art overview of the contemporary management of patients with asymptomatic severe aortic stenosis.