What is the recommended treatment for severe symptomatic aortic stenosis?

Treatment for Severe Symptomatic Aortic Stenosis

For patients with severe symptomatic aortic stenosis, surgical aortic valve replacement (SAVR) is the first-line treatment (Class I, Level of Evidence: B), while transcatheter aortic valve replacement (TAVR) is recommended for patients with prohibitive or high surgical risk. 1

Treatment Algorithm Based on Surgical Risk

1. Low Surgical Risk Patients

• SAVR is indicated (Class I, LOE: B) 1
• Benefits include:
  • Lower mortality (3%) compared to TAVR (3-5%)
  • Lower stroke rate (2%) compared to TAVR (6-7%)
  • Lower risk of paravalvular regurgitation
  • Established long-term durability

2. High or Prohibitive Surgical Risk Patients

• TAVR is recommended for patients with:
  • Prohibitive surgical risk (≥50% risk of mortality/morbidity at 30 days)
  • Frailty, prior radiation therapy, porcelain aorta, severe hepatic/pulmonary disease
  • High surgical risk (STS score ≥8%) 1
• TAVR provides significant survival benefit in inoperable patients:
  • 2-year mortality 43.3% with TAVR vs 68.0% with medical therapy 2
  • Reduced hospitalization rates (35.0% vs 72.5%) 2

3. Intermediate Surgical Risk Patients

• Decision between SAVR and TAVR should be made by a Heart Team
• TAVR is favored in elderly patients suitable for transfemoral access 1

Special Considerations

Left Ventricular Dysfunction

• SAVR is indicated in asymptomatic patients with severe AS and LV systolic dysfunction (LVEF <50%) not due to another cause (Class I, LOE: C) 1
• For symptomatic patients with LV dysfunction and severe AS, AVR is indicated regardless of surgical risk 1

Concomitant Cardiac Surgery

• SAVR is indicated in patients with severe AS undergoing CABG, ascending aortic surgery, or other valve surgery (Class I, LOE: C) 1

Asymptomatic Severe AS

• SAVR is indicated for asymptomatic patients with:
  • Abnormal exercise test showing symptoms clearly related to AS (Class I, LOE: C) 1
  • Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg) with low surgical risk 1

Complications to Consider

SAVR Complications

• Mortality (3%)
• Stroke (2%)
• Prolonged ventilation (11%)
• Thromboembolism and bleeding
• Prosthetic dysfunction
• Higher perioperative complications when combined with CABG 1

TAVR Complications

• Mortality (3-5%)
• Stroke (6-7%)
• Vascular access complications (17%)
• Pacemaker insertion (2-9% with Sapien; 19-43% with CoreValve)
• Paravalvular aortic regurgitation
• Acute kidney injury
• Coronary occlusion, valve embolization, aortic rupture 1, 3

Important Caveats

1. Team-Based Approach: Treatment decisions should involve a multidisciplinary Heart Team including cardiologists, cardiac surgeons, interventional cardiologists, imaging specialists, and anesthesiologists 1

2. Medical Therapy Limitations: Medical therapy alone is not indicated for symptomatic severe AS and should be used only for patients who are truly inoperable or refuse intervention 1

3. Balloon Aortic Valvuloplasty: Only reasonable for palliation in patients who cannot undergo AVR or as a bridge to definitive AVR (Class IIb, LOE: C) 1

4. Risk Assessment: Accurate surgical risk assessment using validated tools (STS score) and consideration of frailty and comorbidities is essential for appropriate treatment selection

5. Anatomical Considerations: Vascular access, aortic valve anatomy, and coronary anatomy must be carefully evaluated when considering TAVR 1

The field of aortic valve intervention continues to evolve rapidly, with TAVR expanding to lower-risk populations as technology improves, but SAVR remains the gold standard for most patients with severe symptomatic AS, especially those at low surgical risk.