What is the treatment for severe aortic stenosis?

Treatment for Severe Aortic Stenosis

For patients with severe aortic stenosis, either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is appropriate, with the specific choice depending on surgical risk, age, comorbidities, and valve anatomy. 1, 2

Diagnostic Criteria for Severe Aortic Stenosis

• Aortic valve area (AVA) ≤1.0 cm² or indexed AVA ≤0.6 cm²/m²
• Peak velocity ≥4.0 m/s or mean gradient ≥40 mmHg 2
• Multiple parameters should be integrated rather than relying on AVA alone

Treatment Decision Algorithm

1. Symptomatic Severe Aortic Stenosis

• Immediate intervention is recommended - delaying treatment in symptomatic patients results in poor outcomes with only 2-3 years average survival without treatment 2
• Surgical risk assessment is critical using Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score:
  • High/extreme risk (STS-PROM ≥8%): TAVR recommended 2
  • Intermediate risk (STS-PROM 3-10%): Either TAVR or SAVR appropriate 2, 3, 4
  • Low risk: Both TAVR and SAVR are options, with SAVR traditionally preferred for younger patients

2. Asymptomatic Severe Aortic Stenosis

• Early TAVR is superior to clinical surveillance in reducing death, stroke, or unplanned cardiovascular hospitalization 5
• Intervention is appropriate in asymptomatic patients with:
  • LVEF <50%
  • Very severe AS
  • Abnormal exercise stress test
  • Rapid progression
  • High-risk profession 2

3. Special Scenarios

• Patients requiring non-cardiac surgery:
  • Valve replacement should be performed before elective non-cardiac surgery
  • TAVR is effective and safe for reducing risk of general anesthesia and major non-cardiac surgery in severe AS patients 6
• Low-flow, low-gradient AS with reduced LVEF:
  • Valve replacement recommended if flow reserve is present on dobutamine stress echo 2

Comparing TAVR vs. SAVR

TAVR Advantages

• Less invasive procedure
• Shorter hospital stay
• Faster recovery
• Lower risk of bleeding and atrial fibrillation 2
• In intermediate-risk patients with transfemoral access, lower rates of death or disabling stroke compared to surgery 4

TAVR Disadvantages

• Higher rates of paravalvular leak
• Higher rates of permanent pacemaker implantation
• Limited long-term durability data 2

SAVR Advantages

• Established long-term durability
• Lower rates of paravalvular leak
• Lower rates of pacemaker implantation 2

SAVR Disadvantages

• Longer recovery time
• Higher rates of bleeding
• Higher rates of atrial fibrillation
• Higher rates of acute kidney injury 2, 4

Common Pitfalls in Management

• Misclassification of symptom status: Many patients reduce activity to avoid symptoms, leading to incorrect "asymptomatic" classification 2
• Undertreatment: Studies show 56% of symptomatic patients do not undergo valve replacement, often due to overestimated surgical risk or misclassified symptom status 7
• Delayed intervention: Waiting until symptoms are severe significantly worsens prognosis 2

Heart Team Approach

A multidisciplinary Heart Team should evaluate each patient with severe aortic stenosis to determine the optimal treatment strategy, considering:

• Patient risk factors
• Valve characteristics
• Comorbidities
• Patient preferences 2