What is the best management for severe aortic stenosis with an aortic valve area of 0.73 cm², ejection fraction (EF) of 45%, and transvalvular gradient of 55 mmHg?

Management of Severe Aortic Stenosis with Reduced Ejection Fraction and High Gradient

Aortic valve replacement (AVR) is strongly recommended for this patient with severe aortic stenosis (AVA 0.73 cm²), reduced ejection fraction (45%), and high transvalvular gradient (55 mmHg), as this represents symptomatic severe high-gradient AS with reduced LV function (Stage D2) requiring prompt intervention. 1

Classification and Diagnosis

This patient presents with:

• Aortic valve area of 0.73 cm² (<1.0 cm²) = severe AS
• Ejection fraction of 45% (<50%) = reduced LV function
• Mean transvalvular gradient of 55 mmHg (>40 mmHg) = high gradient

According to the ACC/AHA guidelines, this represents Stage D2 severe symptomatic AS with reduced left ventricular ejection fraction, characterized by:

• Severely calcified valve with reduced systolic opening
• Aortic valve area ≤1.0 cm²
• Mean gradient ≥40 mmHg
• LVEF <50% 1

Management Algorithm

1. Heart Valve Team Evaluation

   • Multidisciplinary assessment including cardiologists, cardiac surgeons, imaging specialists, and interventional cardiologists 1

2. Risk Stratification

   • Calculate STS Predicted Risk of Mortality score
   • Assess frailty, major organ system dysfunction, and procedure-specific impediments
   • Classify as low risk (<4%), intermediate risk (4-8%), or high risk (>8%) 1

3. Intervention Selection

   • For low to intermediate surgical risk patients:
     • Surgical AVR (SAVR) is recommended
   • For high surgical risk patients:
     • Transcatheter AVR (TAVR) is recommended
   • For prohibitive surgical risk patients:
     • TAVR is the preferred option 1

Evidence Supporting AVR in This Scenario

The evidence strongly supports valve replacement for this patient profile:

• Patients with severe AS, reduced LVEF (<50%), and high gradient (>40 mmHg) have been shown to benefit significantly from AVR with improved survival and functional status 2

• Even in patients with low LVEF and high gradient, AVR is associated with improved ejection fraction and better outcomes compared to medical therapy alone 2, 3

• The 2021 European Heart Journal systematic review of guidelines confirms that AVR is indicated for symptomatic severe AS with reduced ejection fraction 1

Important Considerations

• Pre-procedural Assessment:

  • Coronary angiography to assess for concomitant CAD
  • Detailed assessment of valve anatomy and aortic root dimensions
  • Evaluation of peripheral vascular access if TAVR is considered

• Potential Pitfalls:

  • Delaying intervention in this high-risk profile can lead to progressive LV dysfunction and worse outcomes
  • Patients with reduced LVEF and high gradient have better outcomes than those with low gradient, but still represent a higher-risk group than those with normal LVEF 2
  • Underestimating the severity of AS when LVEF is reduced can lead to inappropriate delays in treatment

• Post-procedural Management:

  • Close monitoring for improvement in LV function
  • Optimization of heart failure therapy if LV dysfunction persists
  • Regular follow-up echocardiography to assess valve function and ventricular remodeling

Special Considerations for Perioperative Management

For patients requiring non-cardiac surgery, the 2024 AHA/ACC perioperative guidelines recommend:

• AVR before elective non-cardiac surgery reduces perioperative risk in patients with severe AS
• If urgent non-cardiac surgery is required, balloon aortic valvuloplasty may be considered as a bridging strategy 1

In conclusion, this patient with severe AS (AVA 0.73 cm²), reduced EF (45%), and high gradient (55 mmHg) has a clear indication for prompt aortic valve replacement, with the specific approach (SAVR vs. TAVR) determined by surgical risk assessment and Heart Valve Team evaluation.