From the Guidelines
For severe symptomatic aortic stenosis, the definitive treatment is valve replacement, either through surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR), as recommended by the 2017 appropriate use criteria for the treatment of patients with severe aortic stenosis 1, 2.
Treatment Options
The choice between SAVR and TAVR depends on surgical risk, age, and comorbidities, with TAVR often preferred for older or higher-risk patients.
- SAVR involves open-heart surgery to replace the valve with a mechanical or biological prosthesis.
- TAVR is less invasive, delivering a new valve via catheter.
Indications for Treatment
According to the 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement, the indications for SAVR and TAVR are as follows:
- SAVR is recommended for symptomatic severe AS, severe AS undergoing CABG, aortic surgery or other valve surgery, and asymptomatic severe AS with certain high-risk features 3.
- TAVR is recommended for patients with severe, symptomatic, calcific stenosis of a trileaflet aortic valve who have aortic and vascular anatomy suitable for TAVR and a predicted survival of 12 months, and who have a prohibitive surgical risk 3.
Medical Therapy
Medical therapy cannot reverse valve narrowing but may help manage symptoms; this includes:
- Diuretics for fluid overload
- Cautious use of vasodilators
- Treatment of hypertension (avoiding excessive blood pressure reduction)
- Beta-blockers and ACE inhibitors should be used cautiously 3.
Other Considerations
- Balloon valvuloplasty may provide temporary relief in specific situations but isn't a permanent solution 3.
- Patients should also receive endocarditis prophylaxis before certain procedures and maintain regular cardiology follow-up to monitor disease progression.
- Asymptomatic or mild-to-moderate aortic stenosis can be managed with watchful waiting and regular echocardiographic monitoring every 6-12 months.
From the Research
Aortic Stenosis Treatment Options
- Aortic valve replacement is recommended for most symptomatic patients with evidence of significant aortic stenosis on echocardiography 4
- Watchful waiting is recommended for most asymptomatic patients, with serial Doppler echocardiography every six to 12 months for severe aortic stenosis 4
- Transcatheter aortic valve replacement (TAVR) may be considered in patients at high or prohibitive surgical risk 4
- Balloon aortic valvuloplasty (BAV) may be used as a bridge to TAVR or surgical aortic valve replacement (SAVR) in high-risk patients 5
Comparison of Treatment Outcomes
- Patients undergoing TAVR had lower all-cause mortality and cardiovascular mortality compared to those undergoing conservative management 6
- TAVR was associated with fewer primary outcome events, including all-cause in-hospital death, acute cerebrovascular accident, and myocardial infarction, compared to BAV 7
- BAV as a bridge to TAVR or SAVR was associated with better mid-term outcomes compared to BAV alone 5
Patient Selection and Management
- Patients with asymptomatic aortic valve stenosis have lower odds of all-cause and cardiovascular mortality when managed with early aortic valve replacement compared to conservative management 6
- Select patients with asymptomatic aortic stenosis may benefit from aortic valve replacement before the onset of symptoms 4
- Patients should be educated about the importance of promptly reporting symptoms to their physicians, and cardiology referral is recommended for all patients with symptomatic moderate and severe aortic stenosis 4