What are the treatment options for aortic stenosis?

Treatment of Aortic Stenosis

For patients with symptomatic severe aortic stenosis, valve replacement through either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) is the only effective treatment to improve survival and quality of life. 1

Diagnosis and Assessment

• Severe aortic stenosis is defined as:

  • Peak aortic valve velocity ≥4 m/sec or mean gradient ≥40 mmHg
  • Aortic valve area (AVA) ≤1.0 cm² (or indexed AVA ≤0.6 cm²/m²) 2

• Multimodality imaging is essential for:

  • Confirming diagnosis and severity
  • Risk stratification
  • Selection of optimal timing and type of intervention 2

Treatment Algorithm Based on Patient Characteristics

Symptomatic Severe Aortic Stenosis

1. High or Extreme Surgical Risk (STS-PROM ≥8%)

   • TAVR is recommended as first-line therapy 1
   • Significant mortality benefit compared to medical therapy (43.3% vs 68.0% mortality at 2 years) 3

2. Intermediate Surgical Risk (STS-PROM 3-10%)

   • Either TAVR or SAVR may be appropriate
   • Decision based on individual factors including age, frailty, and comorbidities 1

3. Low Surgical Risk (STS-PROM <3%)

   • SAVR is traditionally recommended, especially for younger patients
   • TAVR is an emerging alternative in selected cases 1, 2

4. Limited Life Expectancy (<1 year) or Severe Dementia

   • Medical therapy is appropriate
   • Palliative balloon valvuloplasty may be considered 2

Asymptomatic Severe Aortic Stenosis

1. With High-Risk Features

   • AVR is recommended for patients with:
     • LVEF <50%
     • Very severe AS (AVA ≤0.75 cm² with peak velocity ≥4.5 m/s or mean gradient ≥50 mmHg) 2, 1
     • Abnormal exercise test (exercise-induced symptoms, limited capacity, abnormal BP response) 2
     • Rapid progression (increase in peak velocity ≥0.3 m/s/year) 2

2. Without High-Risk Features

   • Watchful waiting with regular monitoring
   • Serial Doppler echocardiography:
     • Every 6-12 months for severe AS
     • Every 1-2 years for moderate AS
     • Every 3-5 years for mild AS 4

Special Clinical Scenarios

Concomitant Conditions

1. Coronary Artery Disease

   • SAVR with CABG is appropriate for all risk categories
   • Catheter-based approaches may be considered for intermediate/high-risk patients with less complex coronary disease 2

2. Non-Cardiac Surgery Required

   • For symptomatic patients: AVR before non-cardiac surgery
   • For asymptomatic patients with elective surgery: AVR may be appropriate
   • For urgent non-cardiac surgery: TAVR, balloon valvuloplasty, or no intervention based on individual case 1

3. Failed Bioprosthetic Valve

   • TAVR or SAVR based on surgical risk
   • SAVR preferred for small surgical prostheses (≤19 mm) with low/intermediate risk 1

4. Low-Flow, Low-Gradient AS with Reduced LVEF

   • Valve replacement recommended if flow reserve is present on dobutamine stress echo
   • Medical management if pseudo-severe AS is confirmed 2

Medical Management Considerations

• No medical therapy has been shown to improve survival in severe AS 4
• ACE inhibitors should be used with caution in patients with AS due to risk of hypotension 5
• Manage concurrent conditions (hypertension, atrial fibrillation, CAD) for optimal outcomes 4
• Educate patients about importance of promptly reporting symptoms 4

TAVR vs SAVR Considerations

• TAVR advantages: Less invasive, shorter hospital stay, faster recovery, lower bleeding risk 1
• TAVR disadvantages: Higher rates of paravalvular leak, permanent pacemaker implantation, limited long-term durability data 1
• SAVR advantages: Established long-term durability, lower paravalvular leak rates 1
• SAVR disadvantages: Longer recovery, higher bleeding rates, higher atrial fibrillation rates 1

Key Pitfalls to Avoid

1. Delaying intervention in symptomatic patients (average survival only 2-3 years without treatment) 2
2. Missing symptoms in elderly patients due to reduced activity or attributing them to aging
3. Failing to recognize low-flow, low-gradient AS patterns which may require additional testing
4. Not considering valve durability in younger patients who may benefit more from SAVR
5. Using ACE inhibitors without caution in AS patients due to risk of hypotension 5

Heart Valve Team evaluation is essential for determining optimal treatment strategy, considering patient risk factors, valve characteristics, and comorbidities 1.