Residual risk from heart failure (HF) among patients with calcific aortic stenosis (AS) undergoing aortic valve replacement (AVR) represents a major obstacle to optimal patient outcomes in terms of survival and quality of life¹ as well as a large economic burden. HF is the most common cause of hospitalization in the year after transcatheter AVR, with rates only slightly lower than in the year prior.² The long-standing paradigm for clinical management of patients with AS can be distilled as (1) monitor asymptomatic patients with progressive AS during a variable latent period with serial echocardiography until the AS is severe; (2) once severe, AVR is recommended, usually after symptoms develop³; and (3) once AVR has been performed, the AS has been fixed. There has been no role for medical therapy specifically to treat AS or its consequences; AVR is the only definitive treatment, and management centers wholly on its timing. Perhaps a reframing of the clinical needs and evidence gaps could stimulate and accelerate progress to improve outcomes for this growing number of patients. We propose prevention and mitigation of HF as a unifying and organizing principle for the treatment of AS that would integrate the valve and ventricle, AVR and medical therapy, and the pre-AVR and post-AVR time periods.

在接受主动脉瓣置换术 (AVR) 的钙化性主动脉瓣狭窄 (AS) 患者中，心力衰竭 (HF) 的残余风险是患者在生存和生活质量方面获得最佳结果的主要障碍¹以及巨大的经济负担。HF 是经导管 AVR 后一年内最常见的住院原因，其发病率仅略低于前一年。²长期存在的 AS 患者临床管理范式可概括为：（1）在可变潜伏期用连续超声心动图监测无症状进展性 AS 患者，直至 AS 严重；(2) 一旦严重，建议进行 AVR，通常在症状出现后³; (3)一旦执行了AVR，AS就被修复了。没有专门用于治疗 AS 或其后果的药物治疗；AVR 是唯一明确的治疗方法，管理完全取决于其时机。也许对临床需求和证据差距的重新定义可以刺激和加速进步，以改善越来越多的患者的结果。我们建议将预防和缓解 HF 作为治疗 AS 的统一和组织原则，将瓣膜和心室、AVR 和药物治疗以及 AVR 前和 AVR 后时间段结合起来。