Is valve replacement considered for patients with moderate aortic stenosis by cardiothoracic (cardiac and thoracic) surgery?

From the Guidelines

Valve replacement is generally not recommended for patients with moderate aortic stenosis in the absence of other indications. Cardiac surgery guidelines typically reserve aortic valve replacement for patients with severe aortic stenosis who are symptomatic or have specific high-risk features. For moderate aortic stenosis, the preferred approach is regular monitoring with echocardiography every 1-2 years and clinical follow-up to detect progression to severe stenosis or development of symptoms. However, valve replacement may be considered in moderate aortic stenosis if the patient is undergoing cardiac surgery for another indication (such as coronary artery bypass grafting or surgery on another valve), or if there is rapid progression of stenosis, reduced left ventricular function, or severe symptoms clearly attributable to the valve condition despite its moderate classification, as suggested by guidelines on the management of valvular heart disease 1.

Some key points to consider in the management of moderate aortic stenosis include:

• The natural history of moderate aortic stenosis is often relatively benign compared to severe stenosis, with a lower risk of sudden cardiac death or heart failure in the short to medium term.
• The risks of surgery generally outweigh the benefits in moderate stenosis, unless there are other indications for cardiac surgery.
• Valve replacement should be considered in patients with moderate AS undergoing CABG, surgery of the ascending aorta or another valve, as indicated by the 2012 guidelines on the management of valvular heart disease 1 and supported by the 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement 1.
• The decision to proceed with valve replacement in moderate aortic stenosis should be individualized for each patient, taking into account their unique needs, preferences, and risk profile, as emphasized in the operationalizing the 2014 ACC/aha guidelines for valvular heart disease 1.

In terms of specific recommendations, valve replacement should be considered in moderate aortic stenosis if the patient is undergoing cardiac surgery for another indication, as this approach can help to minimize the risks associated with surgery while also addressing the underlying valve condition. Additionally, valve replacement may be considered in asymptomatic patients with moderate aortic stenosis who have a low surgical risk and evidence of rapid progression of stenosis or reduced left ventricular function, as these patients may benefit from early intervention to prevent long-term complications. Overall, the management of moderate aortic stenosis requires a careful and individualized approach, taking into account the latest evidence and guidelines, as well as the unique needs and preferences of each patient 1.

From the Research

Valve Replacement for Moderate Aortic Stenosis

• Cardiothoracic surgery may consider valve replacement for patients with moderate aortic stenosis, especially those with symptoms or left ventricular dysfunction, as indicated by recent literature 2, 3, 4.
• Current guidelines recommend aortic valve replacement in patients with severe aortic stenosis in the presence of symptoms or a left ventricular ejection fraction <50% 2.
• However, there is evidence to suggest that patients with moderate aortic stenosis may also benefit from early aortic valve intervention, particularly those with left ventricular dysfunction or symptoms 3, 5.
• The decision to perform valve replacement in patients with moderate aortic stenosis is complex and requires careful evaluation of individual patient factors, including the presence of symptoms, left ventricular function, and overall risk profile 4, 6.
• Multimodality imaging plays a crucial role in risk stratification and guiding clinical decision-making in patients with moderate aortic stenosis 2, 6.
• Transcatheter aortic valve replacement (TAVR) has emerged as a viable treatment option for patients with moderate aortic stenosis, particularly those who are at high risk for surgical aortic valve replacement 4.