Early Valve Replacement Guided by Biomarkers of LV Decompensation in Asymptomatic Patients With Severe AS
Early Valve Replacement Guided by Biomarkers of LV Decompensation in Asymptomatic Patients With Severe AS
Aortic stenosis is the most common valvular disease in the Western world. It is caused by
 progressive narrowing of the aortic valve leading to increased strain on the heart muscle
 which has to work increasingly hard to pump blood through the narrowed valve. Over time the
 heart muscle thickens to generate more force, but eventually the heart fails leading to death
 if the valve is not replaced with an operation. No medical treatments exist to stop or
 reverse the heart valve narrowing. Current clinical guidelines suggest that an operation
 should be performed only when symptoms develop or the heart muscle is visibly weak on cardiac
 ultrasound scanning. However, symptoms can be difficult to interpret and in many patients the
 heart muscle has become irreversibly damaged and the heart fails to recover following
 surgery.

 Using MRI scans of the heart, the investigators have identified heart scarring which seems to
 develop as the heart muscle thickens. Several studies now show that people who have developed
 this scarring are more likely to suffer poor outcomes including death. The investigators have
 also identified clinical risks that predict the presence of scarring.

 The investigators propose a study where patients with severe aortic stenosis but no
 indications for valve replacement as per current guidelines are assessed for those clinical
 risks. If a participant's risk of having scarring is higher they will undergo a cardiac MRI
 scan. If scarring is present participants will be randomised to routine clinical care, or
 referral for valve replacement surgery. Participants with no evidence of scarring will be
 randomised routine care with study follow or not. The investigators of this study hypothesize
 that early surgery will lead to fewer complications and reduced risk of death compared to
 standard care.
Inclusion Criteria:

 1. Severe aortic stenosis (aortic valve jet velocity ≥4.0 m/s, or aortic valve area
 indexed to body surface area <0.6cm2/m2 with aortic jet velocity ≥3.5m/s)

 2. Age over 18 years

 3. No symptoms attributable to aortic stenosis that require aortic valve replacement

 Exclusion Criteria:

 1. Deemed lower risk for mid-wall fibrosis on screening

 2. Planned cardiac surgery

 3. Previous valve replacement

 4. Severe hypertension (systolic >180 or diastolic >110 mmHg)

 5. Acute pulmonary oedema or cardiogenic shock

 6. Left ventricular ejection fraction <50% on cardiac MRI

 7. Significant abnormalities on cardiac MRI that would prevent enrolment

 8. Coexistent severe aortic regurgitation or mitral regurgitation

 9. Coexistent mitral stenosis greater than mild in severity

 10. Coexistent hypertrophic cardiomyopathy or cardiac amyloidosis

 11. Any contraindication to MRI scanning (such as permanent pacemaker)

 12. Advanced renal impairment (glomerular filtration rate <30 mL/min/1.73 m2)

 13. Pregnancy or breast feeding

 14. Patient judged to be unfit to be considered for aortic valve replacement or
 transcatheter aortic valve implantation

 15. Patient declines to consider undergoing valve replacement surgery or transcatheter
 aortic valve implantation

 16. Inability to give informed consent

 17. Previous randomisation into this study