From the Guidelines
Aortic valve replacement is indicated for severe aortic stenosis or regurgitation causing symptoms, left ventricular dysfunction, or in asymptomatic patients with very severe stenosis or regurgitation with rapid progression, with the choice between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) depending on patient age, comorbidities, surgical risk, and valve anatomy. Management strategies for aortic valve replacement include SAVR and TAVR, with SAVR remaining the gold standard for younger, lower-risk patients, while TAVR is preferred for older, higher-risk individuals 1.
Indications for Aortic Valve Replacement
- Severe aortic stenosis or regurgitation causing symptoms (dyspnea, angina, syncope)
- Left ventricular dysfunction
- Asymptomatic patients with very severe stenosis or regurgitation with rapid progression
- Patients with severe AS undergoing CABG, surgery of the ascending aorta or another valve 1
Management Strategies
- Surgical aortic valve replacement (SAVR)
- Transcatheter aortic valve replacement (TAVR)
- Bioprosthetic valves (typically lasting 10-15 years) recommended for patients over 65 or those who cannot tolerate anticoagulation
- Mechanical valves (lasting 20+ years) better for younger patients who can manage lifelong anticoagulation
Post-Procedure Care
- Patients with mechanical valves require warfarin with a target INR of 2.0-3.0
- Patients with bioprosthetic valves need aspirin 75-100mg daily
- All patients require antibiotic prophylaxis for dental procedures
- Regular echocardiographic follow-up at 1 month, 1 year, and then annually to monitor valve function 1
Rehabilitation
- Gradual return to activities
- Most patients achieving significant symptom improvement within 3 months
- Decision ideally made by a multidisciplinary heart team 1
From the Research
Indications for Aortic Valve Replacement
- Aortic stenosis is a common condition that requires surgical treatment, and any patient with symptomatic severe aortic stenosis should be considered for aortic valve replacement 2
- Symptomatic patients with severe aortic regurgitation should be operated on as soon as possible 3
- Asymptomatic patients with significant dilatation of the left ventricle and reduction of systolic pump function should undergo aortic valve replacement 3
- Patients with severe aortic regurgitation and left ventricular dysfunction may benefit from transcatheter aortic valve replacement, which has shown promising short-term outcomes 4
Management Strategies
- The management of patients with severe aortic stenosis in the intensive care unit setting can be challenging, particularly when comorbid medical conditions make aortic valve replacement difficult 2
- Determining whether a patient has symptoms and accurately assessing the severity of stenosis can be difficult, and components of the history and physical examination should be carefully evaluated 2
- Echocardiographic means of determining stenosis severity, such as the Gorlin equation and Doppler continuity equation, should be used to assess the severity of aortic stenosis 5
- Patients with aortic regurgitation and left ventricular dysfunction should be regularly monitored to detect left ventricular dysfunction in due time, and valve replacement should be considered when the patient shows a deterioration of left ventricular function or becomes symptomatic 3
Special Considerations
- Patients with severe left ventricular systolic dysfunction and aortic stenosis or regurgitation are at high risk for mortality and morbidity after aortic valve replacement, and the decision to operate should be made on a case-by-case basis 5, 6
- Prior myocardial infarction is a significant risk factor for perioperative death in patients with severe aortic stenosis and left ventricular dysfunction, and this should be factored into the risk-benefit analysis for these patients 6