What are the treatment options for aortic valve stenosis?

Treatment Options for Aortic Valve Stenosis

Aortic valve replacement (AVR) is the definitive treatment for symptomatic severe 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, 2

Treatment Algorithm Based on Clinical Presentation

Symptomatic Severe Aortic Stenosis

• AVR is rated as "Appropriate" for all patients with symptomatic severe aortic stenosis regardless of surgical risk 1
• Medical management alone is rated as "Rarely Appropriate" for symptomatic patients and should not be considered as a primary treatment strategy 1
• For patients with life expectancy <1 year or those with moderate to severe dementia, medical management may be considered appropriate 1
• Palliative balloon aortic valvuloplasty may be considered in patients with limited life expectancy but is not a definitive treatment 1

Asymptomatic Severe Aortic Stenosis

• For asymptomatic patients with Vmax 4.0-4.9 m/sec without predictors of symptom onset or rapid progression, observation is appropriate while AVR may be appropriate 1
• AVR is appropriate for asymptomatic patients with very severe AS (Vmax ≥5 m/sec), reduced left ventricular function, or positive exercise stress test 2
• Asymptomatic patients with high-risk professions or lifestyle may benefit from early intervention 1

Decision-Making Based on Surgical Risk

High or Extreme Risk (STS-PROM ≥8%)

• TAVR is the preferred treatment option for patients at high or extreme surgical risk 2, 3, 4
• TAVR has demonstrated lower mortality rates compared to medical therapy in patients unsuitable for surgery 4
• At 1 year, TAVR shows similar survival rates to surgery in high-risk patients with different periprocedural risk profiles 3

Intermediate Risk (STS-PROM 3-8%)

• Both TAVR and SAVR are appropriate options for intermediate-risk patients 1, 5
• TAVR with a self-expanding prosthesis has demonstrated non-inferiority to SAVR in intermediate-risk patients at 24 months 5
• TAVR is associated with higher rates of residual aortic regurgitation and need for pacemaker implantation 5
• SAVR is associated with higher rates of acute kidney injury, atrial fibrillation, and transfusion requirements 5

Low Risk (STS-PROM <3%)

• SAVR has traditionally been the standard of care for low-risk patients, though recent evidence suggests TAVR may be appropriate in selected cases 1, 6
• The choice between TAVR and SAVR should consider patient age, valve durability concerns, and anatomical factors 2

Special Considerations

Concomitant Conditions

• For patients with severe AS and significant coronary artery disease, SAVR plus CABG is appropriate 1
• Catheter-based approaches may be appropriate for intermediate or high-risk patients with less complex coronary disease 1
• For patients with severe AS and other valvular disease or aortic pathology, surgical intervention is generally appropriate 1

Low-Flow, Low-Gradient Aortic Stenosis

• In patients with low-flow, low-gradient AS and reduced LV function, dobutamine stress echocardiography should be performed to differentiate true severe AS from pseudosevere AS 2
• AVR is appropriate for confirmed severe AS with flow reserve 2
• Medical management may be appropriate when LV systolic function is profoundly impaired without contractile reserve 1

Failing Bioprosthetic Valves

• For patients with failing bioprosthetic valves, both TAVR (valve-in-valve) and SAVR are appropriate depending on surgical risk 1, 7
• For very small surgical prostheses (≤19 mm), SAVR is preferred in patients with low or intermediate surgical risk due to potentially higher residual gradients after valve-in-valve TAVR 1

Common Pitfalls to Avoid

• Delaying intervention in symptomatic patients can lead to increased mortality 2
• Failing to recognize very severe aortic stenosis (Vmax ≥5 m/sec) in asymptomatic patients 2
• Not involving a multidisciplinary Heart Team in decision-making 2
• Overlooking reduced left ventricular function, which should prompt consideration for AVR even in asymptomatic patients 2