When should I consult cardiothoracic surgery for aortic valve replacement?

From the Guidelines

You should consult cardiothoracic surgery for aortic valve replacement when you have severe symptomatic aortic stenosis, asymptomatic severe aortic stenosis with left ventricular dysfunction, or when undergoing cardiac surgery for other reasons with moderate-to-severe valve disease. According to the most recent guidelines, specific indications for consultation include symptoms like chest pain, shortness of breath, or fainting with severe aortic stenosis, an aortic valve gradient >40 mmHg, or severe aortic regurgitation with left ventricular enlargement 1. The 2017 appropriate use criteria for the treatment of patients with severe aortic stenosis also emphasize the importance of considering factors such as symptom status, left ventricular function, surgical risk, and the presence of concomitant coronary or other valve disease when deciding on the timing of valve replacement 1.

Some key points to consider when deciding on consultation for aortic valve replacement include:

• Severe symptomatic aortic stenosis, where patients experience symptoms such as angina, dyspnea, or syncope 1
• Asymptomatic severe aortic stenosis with left ventricular dysfunction, defined as a left ventricular ejection fraction <50% 1
• Patients undergoing cardiac surgery for other reasons with moderate-to-severe valve disease, where valve replacement may be considered in addition to the primary surgical procedure 1
• Bicuspid aortic valves with associated aortic enlargement, endocarditis with valve destruction, or rapid progression of valve disease, which may require earlier consultation and intervention 1

The decision to consult cardiothoracic surgery for aortic valve replacement involves weighing the natural history of the valve disease against the risks of surgery and considering patient factors like age, comorbidities, and surgical risk scores 1. Consultation with a cardiothoracic surgeon is essential to determine the best course of treatment for each individual patient, taking into account the latest evidence and guidelines, such as those outlined in the 2017 appropriate use criteria for the treatment of patients with severe aortic stenosis 1.

From the Research

Indications for Aortic Valve Replacement

The decision to consult cardiothoracic surgery for aortic valve replacement depends on several factors, including the severity of aortic stenosis, the presence of symptoms, and the patient's overall health status.

• Patients with severe symptomatic aortic stenosis should be considered for aortic valve replacement 2.
• Asymptomatic patients with severe aortic stenosis may also benefit from aortic valve replacement, especially if they have left ventricular systolic dysfunction or other high-risk features 3.
• The choice between surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) depends on the patient's surgical risk, with TAVR being recommended for patients at high or prohibitive surgical risk 4, 5.

Timing of Aortic Valve Replacement

The timing of aortic valve replacement is critical, and delays should be avoided in selected patients.

• Balloon aortic valvuloplasty can be used as a bridge to aortic valve replacement in patients with severe symptomatic aortic stenosis who are at high risk for surgery 6.
• Patients with severe aortic stenosis should be monitored closely, with serial Doppler echocardiography every 6-12 months for severe disease, and every 1-2 years for moderate disease 3.

Patient Selection

Patient selection is crucial in determining the best treatment approach for aortic stenosis.

• Patients with extensive coexisting conditions may not benefit from aortic valve replacement, and the decision to proceed with surgery should be made on a case-by-case basis 4.
• A discussion with the patient about expectations, mortality, and morbidity risks with all management options is essential to aid decision-making 6.