Contemporary Management of Aortic Stenosis: Timing of Intervention and Lifetime Valve Management

Calcific aortic stenosis (AS) is the most relevant valvular heart disease in aging populations and remains both underdiagnosed and undertreated. Screening studies reveal a high prevalence of unrecognized disease, while up to 40% of patients with symptomatic severe AS do not undergo valve intervention, resulting in poor survival. No pharmacologic therapy has yet altered disease progression, although targeted approaches such as lipoprotein(a) inhibition are under investigation.

This paper provides a comprehensive perspective review of the evolving epidemiology, timing of intervention, and long-term management of aortic stenosis, drawing on randomized trials and contemporary clinical data.

Randomized trials have challenged the traditional watchful waiting strategy in asymptomatic severe AS, showing that early aortic valve replacement (AVR) reduces cardiovascular events, though survival benefit depends on patient selection and timing. Moderate AS is increasingly recognized as a high-risk condition, prompting ongoing trials evaluating earlier intervention. As transcatheter aortic valve implantation (TAVI) expands to younger, lower-risk patients, long-term issues-including conduction disturbances, paravalvular leak, cerebrovascular events, valve hemodynamics and durability, and redo feasibility-become central to care. Contemporary data suggest comparable mid-term durability between TAVI and surgery, but lifetime management planning is essential.

Optimal care of aortic stenosis requires earlier diagnosis, optimized procedural strategies, and a lifetime-oriented approach to management, supported by continued investigation into pharmacologic therapy and the timing of intervention.