Introduction.

1. Sex-Male
2. Age >70 years
3. Echocardiogram-Aortic valve area <1 cm²,Pmean >40 mm Hg,Vmax>4cm/ s,LVEF>50%
4. Sign a consent Form to participate in this Study.

Exclusion Criteria

1. Associated CAD
2. Symptoms like Angina, Dyspnoea, Syncope
3. LVEF <50%, Regional Wall Motion Abnormalities in Echocardiogram
4. Age <70 years and >90 years
5. Presence of moderate Mitral regurgitation
6. Previous Bypass or any Valve Surgery
7. Failed to sign the Consent Form

Study Period
This prospective Study was initiated in October 2021, was conducted for 18 months, and was completed in March 2023.
Funding for this Study.
Any external Agencies did not fund this prospective study.
Study Schedule

Study parameters

1. Left ventricular Global Longitudinal Strain (LV-GLS)
2. Left Ventricular Mass Index (LVMI)
3. Left Atrial Volume Index. (LAVI)

Serial echocardiograms in stipulated study intervals measured these three Study parameters. The Patients were given a study Schedule for a physical presence at study intervals in their respective centers.
Transcatheter Aortic Valve Implantation (TAVI)
The Patients of the TAVI group underwent Transfemoral TAVI(TF-TAVI) only. This group of patients had undergone coronary angiograms before inclusion in this study, as Coronary artery Disease is one of the Exclusion criteria. All the Patients were followed after TAVI in 3 months, 6 months, 9 months, 12 months,15 months, and 18 months.
Conservative Watchful Waiting-
The patients assigned to the conservative treatment group were managed with medicines per the current guidelines. The Patients were informed to communicate with their respective centers if they develop symptoms such as Angina, dyspnoea, or Syncope for further evaluation and early surgical Aortic Valve replacement or Transcatheter Aortic valve implantation. This Patient group was followed at the stipulated intervals of 3 months, 3 months, 6 months, 9 months, 12 months, 15 months, and 18 months without fail.

Results

Left ventricular Global longitudinal strain(LV-GLS)
According to the meta-analysis, the Left ventricular global longitudinal strain (LV- GLS) < -16% signifies impaired myocardial dysfunction even if in average Left ventricle ejection Fraction. (9) Considering the multicenter study using different Echocardiography machines, and different echocardiographers, we have taken <-16% as the cutoff value for LV GLS in this prospective study and evaluate the effect of both strategies on GLS.

TAVI                     Watchful waiting

Left ventricular Mass Index(LVMI)*
As per the Studies, it has been noted that there is a regression of left ventricular mass index after transcatheter aortic valve stenosis in case of severe aortic stenosis. (10,11,12)This prospective study defined high LVMI as LVMI > 115 grams/m2.

* study conducted on male patients only.

TAVI                   Watchful waiting

Result of the Study.
Fifty-four patients with asymptomatic severe aortic stenosis were included in this prospective study, with a follow-up time of 18  months. Because of compliance problems, the number of participants was readjusted to 50. 50 % of patients underwent transcatheter aortic valve implantation(TAVI), and 50% experienced a watchful waiting strategy. The age group of the mean(years)+/- 2SD(78+/-7.8) in the TAVI Group and (77+/- 7.7) in the Watchful waiting group. The Aortic Valve area of the TAVI Group (mean) was 0.81cm2(062-0.95), and the watchful waiting group was 0,82cm2 (0.64-0.94). During this Study, in 3 months study intervals, all the patients of both groups were examined clinically and underwent echocardiography. In the follow-up measurements of LV-GLS, LVMI, and LAVI, it was noted that there is substantial improvement in each echocardiographic parameter after TAVI in the case of asymptomatic patients. (as shown in the graphs).In 12 monthly follow-up periods, a LAVI regression of 15.48% was observed. Likewise, an LMVI Reduction of 11.83% was noted. Most importantly, LVGLS improved by 22.79% in 12 months of the study period.
Discussion
This multicenter prospective study compared TAVI versus conservative treatment in individuals with asymptomatic severe aortic stenosis. The study found that patients with early percutaneous intervention (TAVI) had significantly better left ventricular and left atrial function over the follow-up period than those who received conservative therapy. Furthermore, early intervention was linked to enhanced quality of life in these individuals.
In an asymptomatic patient, the choice to undergo TAVI necessitates carefully evaluating the risks of aortic-valve replacement against the hazards of cautious waiting. In individuals with asymptomatic severe aortic stenosis, it appears safe to use an anticipatory waiting strategy and postpone intervention until symptoms occur.
(15) However, this conservative treatment approach has been linked to patient denial of symptoms, deterioration of cardiac functions, and increased intervention risk and complications while waiting for symptoms to develop. (16)This is quite evident from this prospective study as well.
Conclusion
In conclusion, based on the findings of this investigation, transcatheter aortic valve implantation (TAVI) outperforms watchful waiting in patients with asymptomatic severe aortic stenosis (AS). TAVI significantly improves cardiac function parameters, reducing the risk of adverse events, including heart failure and major cardiovascular events, while improving the quality of life.
Although procedural complications were observed with TAVI, they did not outweigh the significant benefits observed. Therefore, TAVI emerges as a favorable intervention for asymptomatic severe AS, providing patients with improved outcomes and potentially preventing the progression of cardiac dysfunctions. Further research and long-term follow-up studies are warranted to validate these findings and establish the long-term effectiveness and safety of TAVI in this specific patient population.