From the Guidelines
Management of critical aortic valve stenosis requires prompt intervention with valve replacement as the definitive treatment, with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) being appropriate based on the patient's surgical risk profile and anatomical considerations, as recommended by the most recent guidelines 1.
Key Considerations
- Patients with severe symptomatic aortic stenosis should be referred for valve replacement, with the choice between SAVR and TAVR depending on their surgical risk profile and anatomical considerations 1.
- Medical therapy while awaiting intervention focuses on symptom management, including careful use of diuretics, avoiding vasodilators, and treating concurrent conditions like atrial fibrillation with rate control 1.
- Regular clinical monitoring is essential, with echocardiographic assessment every 6-12 months for asymptomatic severe stenosis, and balloon aortic valvuloplasty may serve as a bridge to definitive therapy in hemodynamically unstable patients 1.
- After valve replacement, patients require lifelong anticoagulation with warfarin (target INR 2.0-3.0) for mechanical valves or antiplatelet therapy for bioprosthetic valves, and endocarditis prophylaxis is recommended for all prosthetic valves 1.
Treatment Options
- SAVR is generally recommended for patients with low surgical risk, while TAVR is recommended for patients with intermediate to high surgical risk or those who are inoperable 1.
- The decision to proceed with TAVR should be individualized, taking into account the patient's clinical and imaging evaluation, risk category, patient goals and expectations, and futility considerations, as recommended in the updated AHA/ACC Guideline for Management of Patients with Valvular Heart Disease 1.
Quality of Life and Mortality
- Early intervention is crucial, as mortality increases significantly once symptoms develop, with average survival of only 2-3 years without valve replacement 1.
- TAVR has been shown to improve symptoms, quality of life, and survival in patients with severe aortic stenosis, and is a viable alternative to SAVR irrespective of surgical risk 1.
From the Research
Guidelines for Managing Critical Aortic Valve Stenosis
The management of critical aortic valve stenosis involves several strategies, including:
- Balloon aortic valvuloplasty (BAV) as a bridge to aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI) 2, 3
- TAVR as a recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery 4
- Early TAVR for asymptomatic severe aortic stenosis to reduce the incidence of death, stroke, or unplanned hospitalization for cardiovascular causes 5
- BAV followed by staged TAVI as a safe and effective treatment option for patients with low-flow low-gradient aortic stenosis (LFLG-AS) 6
Indications for Balloon Aortic Valvuloplasty
BAV is recommended as a bridge to AVR or TAVI in patients with severe symptomatic aortic stenosis, and can also be used as a trial in patients with undetermined symptoms or as a bridge-to-decision in case of comorbidities 3.
- BAV can be used to improve hemodynamics and quality of life in patients who are excluded from AVR or TAVI
- Technical innovations, such as transradial access and pacing delivered through the wire, have led to a decrease in complications over time
Outcomes of Transcatheter Aortic-Valve Replacement
TAVR has been shown to reduce the rates of death and hospitalization, with a decrease in symptoms and an improvement in valve hemodynamics that are sustained at 2 years of follow-up 4.
- Early TAVR can improve outcomes in patients with asymptomatic severe aortic stenosis, with a reduction in the incidence of death, stroke, or unplanned hospitalization for cardiovascular causes 5
- TAVR can be used in patients with LFLG-AS, with similar results to those with high-gradient aortic stenosis (HG-AS) 6