From the Guidelines
Management of severe aortic stenosis with a reduced ejection fraction of 45% and a loud aortic murmur requires prompt referral for aortic valve replacement (AVR), which is the definitive treatment. The patient should be evaluated by a cardiac surgeon and interventional cardiologist to determine whether surgical AVR or transcatheter AVR (TAVR) is more appropriate based on surgical risk and anatomy. While awaiting intervention, medical management includes cautious use of medications: low-dose beta-blockers (such as metoprolol 25-50 mg twice daily) for rate control, ACE inhibitors at low doses (like lisinopril 2.5-5 mg daily) for afterload reduction, and diuretics (furosemose 20-40 mg daily) if there are signs of congestion. Avoid vasodilators at high doses as they can cause dangerous hypotension in severe stenosis. The patient should restrict strenuous physical activity, maintain adequate hydration, and promptly report symptoms like syncope, chest pain, or worsening shortness of breath. Regular follow-up with cardiology is essential, with echocardiograms every 3-6 months to monitor disease progression. This approach is necessary because severe aortic stenosis with reduced ejection fraction indicates advanced disease with poor prognosis if left untreated, as the narrowed valve creates excessive afterload on the left ventricle, leading to progressive heart failure 1.
Key Considerations
- The presence of severe aortic stenosis with a reduced left ventricular ejection fraction (LVEF) of 45% is a Class I indication for intervention, regardless of symptoms 1.
- The decision to perform surgical AVR or TAVR should be made by a multidisciplinary team, including a cardiac surgeon and interventional cardiologist, based on individual patient characteristics and anatomy 1.
- Medical management should be optimized, but should not delay surgical decision-making, as prompt intervention is crucial to improve outcomes in patients with severe aortic stenosis and reduced LVEF 1.
- Regular follow-up with cardiology and monitoring of disease progression with echocardiograms is essential to ensure timely intervention and optimal management of the patient's condition 1.
From the Research
Management of Severe Aortic Stenosis with Reduced LVEF
The management of a patient with a loud aortic murmur, severe aortic stenosis, and a reduced left ventricular ejection fraction (LVEF) of 45% involves several considerations. Key points to consider include:
- The patient's LVEF is below the normal threshold, indicating impaired left ventricular function 2, 3, 4, 5.
- Severe aortic stenosis with an LVEF <50% is a class I indication for aortic valve intervention 2.
- Aortic valve replacement can lead to significant improvement in LVEF and functional status, even in patients with severely impaired left ventricular function 3, 5.
- The decision to proceed with aortic valve replacement should be based on individual patient characteristics, including the presence of symptoms, LVEF, and other comorbidities 4, 6.
Predictors of Outcome
Several factors can predict outcome in patients with severe aortic stenosis undergoing aortic valve replacement, including:
- LVEF: a powerful predictor of outcome, with lower LVEF associated with increased mortality 4.
- Left ventricular myocardial mass index (LVMI): a higher LVMI is associated with poorer outcomes 3.
- Presence of coronary artery disease: patients with significant coronary disease may have higher operative mortality and poorer outcomes 5.
Treatment Options
Treatment options for patients with severe aortic stenosis and reduced LVEF include:
- Aortic valve replacement: can lead to significant improvement in LVEF and functional status 3, 5.
- Transcatheter aortic-valve replacement (TAVR): may be a suitable option for patients at high surgical risk or with significant comorbidities 6.
- Medical management: may be considered for patients who are not candidates for aortic valve replacement or TAVR, although this is generally associated with poorer outcomes 2, 4.