What are the management options for aortic stenosis?

Management of Aortic Stenosis

Valve intervention (TAVR or SAVR) is recommended for all symptomatic patients with severe aortic stenosis, with the choice between transcatheter and surgical approaches determined primarily by age, surgical risk, and anatomical considerations. 1

Diagnosis and Classification

Severe aortic stenosis is defined by:

• Valve area <1.0 cm²
• Mean gradient ≥40 mmHg
• Maximum velocity ≥4 m/s 1

Low-flow, low-gradient AS requires dobutamine stress echocardiography to distinguish true-severe from pseudo-severe AS 1

Indications for Intervention

Valve intervention is recommended for:

• Symptomatic patients with severe AS (dyspnea, heart failure, angina, syncope)
• Asymptomatic patients with:
  • Reduced left ventricular ejection fraction (<50-55%)
  • Rapid progression (velocity increase >0.3 m/s/year)
  • Very severe AS (velocity >5 m/s)
  • Elevated BNP levels 1

Recent evidence suggests early TAVR is superior to clinical surveillance in asymptomatic patients with severe AS, reducing the composite endpoint of death, stroke, or unplanned cardiovascular hospitalization 2

Age-Based Approach to Valve Selection

• <65 years: SAVR preferred
• 65-75 years: SAVR generally preferred over TAVR
• 75-80 years: Either SAVR or TAVR (individualized decision)

• 80 years: TAVR preferred 1

Surgical Risk-Based Approach

• STS-PROM >8%: TAVR preferred
• STS-PROM ≤8%: Either SAVR or TAVR appropriate 1

Special Anatomical Considerations

• Concomitant procedures needed (CABG, mitral valve surgery): SAVR recommended
• Valve selection for SAVR:
  • <50 years: Mechanical valve
  • 50-60 years: Mechanical valve preferred
  • 60-65 years: Either mechanical or bioprosthetic

  • 65 years: Bioprosthetic valve 1

For younger low-risk patients (<75 years), long-term data on TAVR durability are still lacking compared to the well-established durability of surgical valves, which should be considered in the decision-making process 3

Medical Management

• Statin therapy for hyperlipidemia for cardiovascular risk reduction
• Antihypertensive therapy:
  • Start at low doses and gradually titrate
  • ACE inhibitors/ARBs may be advantageous
• Beta blockers for patients with reduced ejection fraction, prior MI, arrhythmias, or angina
• Use diuretics sparingly in patients with small LV chamber dimensions 1

Monitoring and Follow-up

• Severe AS: Echocardiography every 6 months
• Moderate AS: Echocardiography every 12 months
• Regular imaging surveillance to monitor aortic diameter (MRI preferred for follow-up) 1

Management of Urgent Situations

• Cardiogenic shock with severe AS: Urgent valve intervention (TAVR or SAVR)
• Balloon aortic valvuloplasty (BAV) as bridge to definitive therapy when immediate valve replacement not feasible
• TAVR may be considered as bridge to definitive treatment for patients needing urgent non-cardiac surgery 1

Long-term Outcomes

Five-year data comparing TAVR vs SAVR in low-risk patients show no significant differences in composite outcomes of death, stroke, or rehospitalization. Valve hemodynamics remain excellent with both approaches, with bioprosthetic valve failure rates of 3.3% for TAVR and 3.8% for SAVR 4

Heart Failure and Aortic Stenosis

For patients with concomitant heart failure and aortic stenosis, a multidisciplinary approach involving heart failure specialists is crucial, with dedicated pre-procedural assessment and careful post-procedural follow-up 5

Palliative Care Considerations

Palliative care may be appropriate for patients with life expectancy <1 year or <25% chance of survival with benefit at 2 years 1

Common Pitfalls and Caveats

• Delaying intervention in symptomatic patients significantly worsens outcomes
• Underestimating the severity of AS in low-flow states
• Failing to recognize symptoms, which may be subtle or attributed to aging
• Not considering valve intervention in elderly patients who could benefit
• Inadequate monitoring of asymptomatic patients with severe AS