How often do we operate too late in aortic stenosis?

The management of asymptomatic severe aortic stenosis remains controversial. Despite a good outcome in terms of mortality, the left ventricle may not recover fully after aortic valve replacement and patients may have impaired exercise ability. Routine assessment of the left ventricle is dominated by transverse systolic function to the relative neglect of long-axis and diastolic function. Long-axis dysfunction develops earlier than transverse dysfunction and may correlate with exercise ability. Reported symptoms can be unreliable and exercise testing reveals significant limitation in many apparently asymptomatic patients. Exercise testing and echocardiographic markers of early LV systolic dysfunction may help to refine the timing of surgery in patients with apparently asymptomatic severe aortic stenosis.