Priority 5 from the Heart Surgery PSP

UNCERTAINTY: When should heart valve intervention occur for patients without symptoms? (JLA PSP Priority 5)
Overall ranking 5
JLA question ID 0088/5
Explanatory note People with severe valve disease take years to develop symptoms that include shortness of breath, chest pain, or even sudden death. Some patients may never develop symptoms at all. Major heart surgery is a very good treatment for patients with symptoms but can cause complications and is often associated with prolonged recovery. The dilemma is therefore: should we operate in everyone when valve disease is severe to avoid the risk of heart failure and death or wait until symptoms develop so that patients are spared unnecessary major surgery? ~ Should aortic valve replacement be performed before symptoms develop secondary to aortic stenosis? Would long term survival be improved if the surgery was undertaken before the onset of symptoms? 
Evidence

Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 2014;63(22):2438-88;
Falk V, Baumgartner H, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017;52(4):616-64.
Health Research Classification System category Cardiovascular
Extra information provided by this PSP
Original uncertainty examples Would long term survival following aortic valve replacement for aortic valve stenosis be improved if surgery was undertaken before the onset of symptoms? Are tricuspid valve repairs indicated for annulus diameter >35mm? 
Submitted by 1x patient, 11 x healthcare professional
PSP information
PSP unique ID 0088
PSP name Heart Surgery
Total number of uncertainties identified by this PSP. 45  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 11 July 2019