What is the recommended treatment for severe symptomatic aortic stenosis diagnosed by echocardiogram (echo)?

Treatment for Severe Symptomatic Aortic Stenosis Diagnosed by Echocardiogram

Aortic valve replacement (AVR) is the recommended treatment for severe symptomatic aortic stenosis, with the choice between transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) based on surgical risk assessment by a Heart Team. 1

Treatment Algorithm Based on Clinical Presentation

For Symptomatic Severe Aortic Stenosis:

• AVR is rated as "Appropriate" (score 8-9) for all patients with symptomatic severe aortic stenosis regardless of surgical risk 1
• Medical management alone is rated as "Rarely Appropriate" (score 1-3) for these patients 1

For Patients with Reduced Left Ventricular Function:

• AVR is strongly recommended (rated 9/9) for patients with severe AS and reduced LVEF (<50%) 1
• This recommendation applies regardless of surgical risk, with medical management alone considered "Rarely Appropriate" (score 1-2) 1

Decision-Making Based on Surgical Risk

The Heart Team should assess surgical risk to determine the optimal intervention approach:

1. High-Risk or Inoperable Patients:

   • TAVR is recommended as the preferred treatment 1, 2
   • Shows significant mortality benefit compared to standard therapy (43.3% vs 68.0% mortality at 2 years) 2

2. Intermediate-Risk Patients:

   • Both TAVR and SAVR are appropriate options 1
   • TAVR should be considered when favored by the Heart Team based on individual risk profile and anatomic suitability 1

3. Low-Risk Patients:

   • Both TAVR and SAVR are appropriate options 3
   • Recent evidence shows excellent outcomes with TAVR in low-risk patients (zero mortality and zero disabling stroke at 30 days) 3

Special Considerations

• Very Severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg):

  • AVR is rated "Appropriate" (score 7-8) even in asymptomatic patients 1
  • Medical management is "Rarely Appropriate" (score 2) when surgical risk is low 1

• Low-Flow, Low-Gradient AS with Reduced LVEF:

  • Low-dose dobutamine stress echocardiography should be considered to differentiate true severe AS from pseudo-severe AS 1
  • AVR is appropriate for confirmed severe AS with flow reserve 1

• Concurrent Cardiac Surgery:

  • AVR is strongly recommended (rated 9/9) when a patient with severe AS is undergoing another cardiac surgery or ascending aortic surgery 1

Procedural Considerations

• TAVR Benefits:

  • Lower rates of rehospitalization compared to medical therapy (35.0% vs 72.5% at 2 years) 2
  • Better valve hemodynamics compared to SAVR (lower mean gradients) 4
  • Shorter hospital length of stay (2.0 ± 1.1 days in low-risk patients) 3

• TAVR Concerns:

  • Higher rate of paravalvular leak compared to SAVR (6.8% vs 0.0% at 3 years) 4
  • Potential for subclinical leaflet thrombosis (observed in 14% of patients at 30 days in one study) 3
  • Long-term durability data still accumulating 5

Common Pitfalls to Avoid

• Delaying intervention in symptomatic patients: Mortality increases dramatically once symptoms develop; prompt referral for AVR is essential 1
• Overlooking reduced LVEF: Even asymptomatic patients with LVEF <50% should be referred for AVR 1
• Failing to recognize very severe AS: Patients with Vmax ≥5 m/sec or mean gradient ≥60 mmHg are at higher risk for adverse outcomes and should be considered for earlier intervention 1
• Not involving a multidisciplinary Heart Team: The decision between TAVR and SAVR should involve cardiologists, cardiac surgeons, imaging specialists, and other relevant specialists 1