What is the recommended treatment for severe aortic stenosis?

Treatment of Severe Aortic Stenosis

Aortic valve replacement (AVR) is the definitive treatment for severe aortic stenosis, with the specific approach (transcatheter or surgical) determined by surgical risk, age, and comorbidities. 1

Treatment Algorithm Based on Patient Characteristics

Symptomatic Severe Aortic Stenosis

• Immediate intervention is recommended for all symptomatic patients with severe aortic stenosis (AS) 1
• Without treatment, symptomatic severe AS has a poor prognosis with average survival of only 2-3 years 1

Treatment Options Based on Surgical Risk

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

   • Surgical AVR (SAVR) is recommended, especially for younger patients 1
   • TAVR may be considered as an alternative in selected cases 1

2. Intermediate Surgical Risk (STS-PROM 3-8%)

   • Either TAVR or SAVR is appropriate 1
   • Consider patient factors such as age, frailty, and comorbidities

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

   • TAVR is recommended 1
   • Significant mortality benefit compared to medical treatment alone 2

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

   • Medical therapy is appropriate
   • Palliative balloon valvuloplasty may be considered 1

Asymptomatic Severe Aortic Stenosis

For asymptomatic patients with severe AS, intervention is recommended in the following scenarios 3:

1. LVEF <50% - AVR is appropriate regardless of surgical risk (rated 8-9/9)
2. Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg) - AVR is appropriate (rated 7-8/9)
3. Abnormal exercise stress test - AVR is appropriate (rated 8/9)
4. Rapid progression or predictors of symptom onset (e.g., ΔVmax >0.3 m/s/year, severe valve calcification, elevated BNP) - AVR is appropriate (rated 7-8/9)
5. High-risk profession or lifestyle requiring high physical performance - AVR is appropriate (rated 7/9)

Special Considerations

Concomitant Coronary Artery Disease

• SAVR with CABG is appropriate for all risk categories
• For intermediate/high-risk patients with less complex coronary disease, catheter-based approaches may be considered 1

Low-Flow, Low-Gradient AS with Reduced LVEF

• Valve replacement is recommended if flow reserve is present on dobutamine stress echo 1
• Studies show dramatic improvement in LV function after AVR, with ejection fraction increasing from 0.34 to 0.63 4

Failed Bioprostheses

• TAVR or SAVR may be performed depending on surgical risk
• SAVR is preferred for patients with small surgical prostheses (≤19 mm) and low to intermediate surgical risk 1

Comparison of TAVR vs. SAVR

TAVR Advantages

• Less invasive procedure
• Shorter hospital stay and faster recovery
• Lower risk of bleeding and atrial fibrillation 1
• In high-risk patients, TAVR shows similar 1-year mortality to SAVR (24.2% vs 26.8%) 5

TAVR Disadvantages

• Higher rates of paravalvular leak
• Higher rates of permanent pacemaker implantation
• Limited long-term durability data 1
• Higher stroke rates (5.1% vs 2.4% at 1 year) 5

SAVR Advantages

• Established long-term durability
• Lower rates of paravalvular leak and pacemaker implantation 1

SAVR Disadvantages

• Longer recovery time
• Higher rates of bleeding and atrial fibrillation 1

Monitoring and Follow-up

For asymptomatic patients with severe AS who are managed conservatively:

• Serial Doppler echocardiography every 6-12 months 6
• Patient education about promptly reporting symptoms 6
• Consider beta-blockers and statins, which may improve survival in unoperated patients 7

Common Pitfalls to Avoid

1. Delaying intervention in symptomatic patients - This significantly worsens prognosis
2. Misclassifying patients as "asymptomatic" - Many patients reduce their activity to avoid symptoms
3. Overlooking high-risk features in asymptomatic patients (reduced LVEF, very severe AS, abnormal stress test)
4. Failing to use a Heart Team approach for complex cases
5. Underestimating the mortality benefit of AVR in appropriate asymptomatic patients - Studies show dramatic improvement in survival with AVR (90% vs 38% 5-year survival) 7