What are the treatment options for severe aortic stenosis?

Treatment Options for Severe Aortic Stenosis

For patients with severe aortic stenosis, aortic valve replacement (AVR) is the definitive treatment that improves survival and quality of life, with the choice between surgical (SAVR) or transcatheter (TAVR) approaches determined by patient risk factors, valve characteristics, and comorbidities. 1

Decision Algorithm for Severe Aortic Stenosis Management

Step 1: Determine Symptom Status and Severity

• Symptomatic severe AS (dyspnea, angina, syncope)
  • Immediate intervention recommended
  • Mortality benefit is clear and established
• Asymptomatic severe AS
  • Assess for high-risk features:
    • Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg)
    • Reduced LVEF (<50%)
    • Abnormal exercise test
    • Rapid progression (ΔVmax >0.3 m/s/year)
    • Severe valve calcification
    • Elevated BNP
    • Excessive LV hypertrophy

Step 2: Risk Stratification

• Low surgical risk (STS-PROM <3%)
• Intermediate surgical risk (STS-PROM 3-10%)
• High surgical risk (STS-PROM >8% or other high-risk features)
• Prohibitive/extreme risk (STS-PROM >15% or unsuitable for surgery)

Step 3: Select Intervention Based on Risk Profile

Symptomatic Severe AS:

• High/Extreme Risk: TAVR is appropriate (Class I recommendation) 1, 2

  • TAVR reduces mortality by 50% compared to medical therapy in inoperable patients 3
  • 5-year mortality: 71.8% with TAVR vs 93.6% with medical therapy 3

• Intermediate Risk: Both TAVR and SAVR are appropriate 1

  • Consider patient-specific factors:
    • Age
    • Frailty
    • Comorbidities
    • Valve anatomy
    • Access considerations

• Low Risk: Both TAVR and SAVR are appropriate 1, 4, 5

  • Recent data shows TAVR is non-inferior to SAVR at long-term follow-up (6 years) 4
  • TAVR shows lower 1-year mortality (2.1% vs 3.5%) 5
  • Consider valve durability for younger patients

Asymptomatic Severe AS:

• With high-risk features: AVR (TAVR or SAVR) is appropriate 1

  • Very severe AS (Vmax ≥5 m/sec)
  • Reduced LVEF
  • Abnormal exercise test

• Without high-risk features: Medical management with close monitoring is appropriate 1

  • AVR may be considered in low-risk surgical candidates

Step 4: Consider Special Scenarios

• Concomitant cardiac surgery needed: SAVR is appropriate 1
• Failing bioprosthetic valve: Valve-in-valve TAVR is appropriate for high-risk patients 1
• Need for non-cardiac surgery:
  • For symptomatic severe AS: AVR before non-cardiac surgery is appropriate 1
  • For asymptomatic severe AS: AVR before elective major surgery is appropriate 1

Comparison of Treatment Options

Medical Management

• Appropriate for: Truly asymptomatic patients without high-risk features
• Limitations: Poor outcomes once symptoms develop
• Requirements: Close clinical follow-up, serial echocardiography

Balloon Aortic Valvuloplasty (BAV)

• Appropriate for: Bridge to definitive therapy or palliative treatment
• Limitations: Temporary relief, high restenosis rates
• Complications: Stroke, vascular injury, aortic regurgitation

Surgical Aortic Valve Replacement (SAVR)

• Advantages:
  • Established long-term durability
  • Lower rates of paravalvular leak
  • Lower pacemaker implantation rates
• Disadvantages:
  • Longer recovery time
  • Higher rates of bleeding
  • Higher rates of atrial fibrillation
  • Sternotomy-related complications

Transcatheter Aortic Valve Replacement (TAVR)

• Advantages:
  • Less invasive
  • Shorter hospital stay
  • Faster recovery
  • Lower risk of bleeding
  • Lower risk of atrial fibrillation
• Disadvantages:
  • Higher rates of paravalvular leak
  • Higher rates of permanent pacemaker implantation
  • Limited long-term durability data
  • Higher rates of vascular complications

Important Caveats and Pitfalls

1. Don't delay intervention in symptomatic patients - mortality increases dramatically once symptoms develop

2. Don't miss pseudo-severe AS in patients with reduced LVEF - low-flow, low-gradient AS requires careful evaluation with dobutamine stress echocardiography

3. Consider valve durability - younger patients may benefit from SAVR due to better established long-term durability

4. Recognize high-risk anatomical features for TAVR:

   • Bicuspid valves
   • Heavy calcification
   • Small annulus size
   • Unfavorable coronary ostia height

5. Watch for complications specific to each approach:

   • TAVR: Paravalvular leak, conduction abnormalities, vascular complications
   • SAVR: Bleeding, atrial fibrillation, prolonged recovery

The evidence strongly supports that timely intervention with either TAVR or SAVR significantly improves survival and quality of life in appropriately selected patients with severe aortic stenosis 1, 6.