Advancing Aortic Stenosis Care in Asia-Pacific

The cardiovascular landscape within the Asia-Pacific is undergoing a transformative shift. The increasing adoption of transcatheter aortic valve replacement (TAVR) in this region reflects its effectiveness and the growing recognition of aortic stenosis (AS) as a significant health concern, especially given the aging population.

Featured in this issue of JACC: Asia, the Asian Pacific Society of Cardiology (APSC) presents a position statement on the use of TAVR in the management of AS.¹ Authored by a group of distinguished professionals, including cardiologists, cardiac surgeons, and imaging specialists, this statement is co-led by co-first authors Jonathan Yap from Singapore, Kentaro Hayashida from Japan, and Michael Kang Yin Lee from Hong Kong, China, along with corresponding author Jack Tan Wei Chieh from Singapore. Their collective expertise, drawn from diverse backgrounds across Asia, ensures that the position statement is firmly rooted in regional insights and experiences. They employ the Grading of Recommendations Assessment, Development, and Evaluation system to rigorously appraise evidence and formulate guidance that is consensus-driven. The document offers practical advice on the frequency of echocardiographic follow-up, intervention thresholds for asymptomatic and symptomatic AS patients, and the choice between TAVR and surgical aortic valve replacement. It also delves into preprocedural evaluation, revascularization in patients with pre-existing coronary artery disease, procedural techniques, and post-TAVR antithrombotic therapy.

The document's exploration of special scenarios is particularly illuminating, underscoring the necessity for region-specific, tailored approaches. It addresses the proportion of Asian patients with small annuli who have shown favorable outcomes with TAVR. It suggests a thorough evaluation of valve hemodynamics, coronary occlusion risks, and potential future interventions, reflecting a thoughtful approach to patient care in this complex scenario. Another anatomical challenge posed by the small body size of Asians is the small femoral artery. For patients who are not suitable for transfemoral TAVR, the statement recommends considering alternative access routes. The management of severe AS in patients with bicuspid aortic valve (BAV) is another scenario with significant regional implications. The position statement recognizes the prevalence of BAV in Asia and the associated complexities in TAVR. The statement's cautious optimism regarding TAVR in BAVs reflects a balanced view, emphasizing the need for careful patient selection and procedural planning.

The authors of the APSC Position Statement are to be commended for their rigorous scientific approach and dedication. Their work represents a significant contribution to the cardiovascular field, offering a roadmap for managing AS that is evidence-based and considers regional variations in patient demographics and health care infrastructure. This position statement is a must-read for cardiovascular specialists, both within Asia and internationally. It provides a comprehensive framework for understanding the intricacies of TAVR in AS, along with practical recommendations that can be applied across different health care settings. By offering region-specific insights and a patient-centered approach, this document serves as an invaluable resource for clinicians navigating the complexities of TAVR in AS management.