Left ventricular hypertrophy in isolated aortic stenosis: primetime for the ventricle

Aortic stenosis is the most common type of valvular heart disease and its recent increase is related to aging. The decreased aortic valve area imposes a chronic systolic pressure overload to the left ventricle. In response, the ventricle hypertrophies in an attempt to normalize the increased wall stress, but this response is not uniform in patients with similar degrees of stenosis and its regression after surgical correction is variable, suggesting that several factors, other than load, can explain these differences. These findings are particularly important since the presence of left ventricular hypertrophy after aortic valve replacement is an independent predictor of worse outcome, probably because it indicates irreversible remodeling. Age, gender, hypertension, patient-prosthesis mismatch and interstitial remodeling also play an important role in this setting, raising the possibility of intervention beyond valve replacement. The possibility of combining estrogen treatment, antihypertensive agents, antioxidants and modulators of the renin-angiotensin-aldosterone system with surgical treatment to promote reverse remodeling is very appealing. On the other hand, a preventive strategy to intervene earlier in patients with significant left ventricular mass and avoid patient-prosthesis mismatch, especially in the younger and those with systolic dysfunction, can have a significant impact on prognosis. Further evidence, with well designed clinical trials, is needed but the spotlight must be in the ventricle, not the valve.