What is the management approach for senile aortic stenosis?

Management of Senile Aortic Stenosis

Aortic valve replacement is the definitive treatment for senile aortic stenosis, with the choice between surgical (SAVR) or transcatheter (TAVI) approaches determined primarily by patient age, surgical risk, and anatomical considerations. 1

Diagnosis and Assessment

• Echocardiography: The cornerstone of diagnosis

  • Severe AS defined as: peak velocity ≥4 m/s, mean gradient ≥40 mmHg, valve area ≤1.0 cm² 1
  • Assess LV function, valve calcification, and other cardiac structures

• Risk Stratification:

  • Surgical risk assessment using validated scores (STS-PROM, EuroSCORE II) 1
  • Evaluation by a multidisciplinary Heart Team is essential (Class I recommendation) 1

Management Algorithm

1. Symptomatic Severe AS

• Symptoms: Angina, syncope, dyspnea, heart failure
• Recommendation: Prompt valve replacement (Class I) 1
  • Age ≥75 years: TAVI generally preferred
  • Age <75 years: SAVR generally preferred, especially with longer life expectancy
  • High surgical risk: TAVI recommended

2. Asymptomatic Severe AS

• With LV dysfunction (LVEF <50-55%): Valve replacement recommended 1
• With normal LV function:
  • Watchful waiting with regular follow-up is generally appropriate 1, 2
  • Consider early intervention if:
    • Very severe AS (velocity ≥5.0 m/s or mean gradient ≥60 mmHg) 1
    • Rapid progression (velocity increase ≥0.3 m/s/year) 3
    • Moderate-severe valve calcification 3
    • Abnormal exercise test (symptoms, blood pressure drop) 1
    • Elevated BNP levels 1

3. Surveillance for Asymptomatic Patients

• Severe AS: Clinical evaluation every 6 months, echocardiography every 6-12 months 1, 2
• Moderate AS: Clinical evaluation yearly, echocardiography every 1-2 years 1, 2
• Mild AS: Clinical evaluation yearly, echocardiography every 3-5 years 1, 2

Special Considerations

Low-Flow, Low-Gradient AS

• Common in elderly patients with reduced LV function
• Dobutamine stress echocardiography recommended to distinguish true severe AS from pseudo-severe AS 1
• Valve replacement beneficial in true severe AS with flow reserve 1

Moderate AS with Heart Failure

• Emerging evidence suggests potential benefit of early TAVI
• The TAVI UNLOAD trial is investigating this approach 1

Concomitant Cardiac Amyloidosis

• Present in 6-25% of elderly AS patients
• Associated with higher mortality regardless of intervention type 1
• Consider screening in appropriate patients

Choosing Between SAVR and TAVI

• Age: Major determinant - TAVI generally preferred for patients ≥75 years 1, 4
• Surgical Risk: TAVI preferred for intermediate to high surgical risk 1
• Anatomical Considerations:
  • Bicuspid valve: SAVR may be preferred
  • Hostile calcium: Individualized decision
  • Coronary access concerns: SAVR may be preferred

Pitfalls to Avoid

1. Delaying intervention in symptomatic patients: Mortality increases dramatically once symptoms develop 3

2. Misattributing symptoms in elderly patients: Exercise testing can clarify symptom status when unclear 1

3. Overlooking rapid progression: Patients with moderate-severe valve calcification and rapid progression (≥0.3 m/s/year) have poor prognosis and should be considered for early intervention 3

4. Neglecting surveillance: Regular clinical and echocardiographic follow-up is essential for asymptomatic patients 1, 2

5. Failing to recognize low-flow, low-gradient AS: May require additional testing (dobutamine stress echo) for proper assessment 1

The management of senile aortic stenosis requires careful evaluation of symptoms, valve hemodynamics, LV function, and surgical risk to determine optimal timing and approach to intervention, with the goal of improving survival and quality of life.