What is the treatment for severe aortic stenosis?

Treatment of Severe Aortic Stenosis

Aortic valve replacement (AVR) is the definitive treatment for severe aortic stenosis, with the choice between surgical (SAVR) or transcatheter (TAVR) approaches determined by patient risk factors, symptoms, and comorbidities. 1

Patient Assessment and Decision-Making Algorithm

Symptomatic Severe Aortic Stenosis

• Immediate intervention is mandatory for all symptomatic patients as mortality increases dramatically once symptoms develop 1
• Risk stratification determines the approach:
  • High/extreme risk patients (STS-PROM ≥8%): TAVR is the preferred approach (Class I) 1
  • Intermediate risk patients (STS-PROM 3-10%): Both TAVR and SAVR are appropriate 2, 1
  • Low risk patients (STS-PROM <3%): Both TAVR and SAVR are appropriate with consideration of patient-specific factors 1

Asymptomatic Severe Aortic Stenosis

Risk stratification and presence of high-risk features determine management:

1. AVR is appropriate (median score 7-9) for asymptomatic patients with: 2

   • LVEF <50% with severe AS (Vmax ≥4 m/sec)
   • Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg)
   • Abnormal exercise stress test
   • High-risk profession/lifestyle requiring uninterrupted physical capability
   • ≥1 predictors of rapid progression with low surgical risk

2. No intervention is appropriate (median score 7) for asymptomatic patients with: 2

   • LVEF ≥50%
   • Vmax 4.0-4.9 m/sec
   • Negative exercise test
   • No predictors of symptom onset or rapid progression

Specific Treatment Considerations

SAVR Benefits and Indications

• Established long-term durability (important for younger patients) 1, 3
• Lower rates of paravalvular leak and pacemaker implantation 1
• Preferred for patients requiring concomitant cardiac surgery 1
• Options include mechanical valves (requiring lifelong anticoagulation) or bioprosthetic valves 4

TAVR Benefits and Indications

• Less invasive with shorter hospital stay and faster recovery 1
• Lower risk of bleeding and atrial fibrillation 1
• Preferred for high/extreme risk patients 1
• Option for valve-in-valve procedures for failing bioprosthetic valves 5

Special Scenarios

1. Patients with failing bioprosthetic valves:

   • Valve-in-valve TAVR recommended for high-risk patients 1, 5

2. Patients requiring non-cardiac surgery:

   • AVR before surgery for symptomatic severe AS 1
   • AVR before elective major surgery for asymptomatic severe AS 1

3. Patients undergoing other cardiac surgery:

   • AVR is appropriate (median score 9) regardless of symptoms 2

Potential Complications to Monitor

• TAVR-specific: Paravalvular leak, conduction abnormalities requiring permanent pacemaker, vascular complications 1
• SAVR-specific: Bleeding, atrial fibrillation, longer recovery time 1

Lifetime Management Considerations

For younger patients (<75 years), consider valve durability and potential need for future interventions:

• Initial valve choice impacts feasibility of subsequent procedures 4, 3
• Many patients may require 2-3 interventions during their lifetime 4
• When SAVR is selected as primary procedure, valve type and potential aortic root enlargement should be considered to facilitate future valve-in-valve interventions 4

The Heart Team approach, incorporating multiple specialists, is essential for determining the optimal treatment strategy for each patient with severe aortic stenosis, particularly when weighing the benefits and risks of TAVR versus SAVR.