Is aortic valve (AV) replacement the recommended treatment for aortic stenosis?

Aortic Valve Replacement for Aortic Stenosis

Surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) is the definitive recommended treatment for symptomatic severe aortic stenosis, as it is the sole effective therapy that improves survival and quality of life. 1

Indications for Aortic Valve Replacement

Symptomatic Severe Aortic Stenosis

• AVR is indicated as a Class I recommendation (Level of Evidence: B) for all patients with symptomatic severe aortic stenosis 1
• Without valve replacement, symptomatic severe AS has a poor prognosis with average survival reduced to 2-3 years 1
• Medical therapy alone is rated as "Rarely Appropriate" for symptomatic severe AS 2

Asymptomatic Severe Aortic Stenosis

• AVR is recommended (Class IIb) for asymptomatic patients with:
  • Extremely severe AS (AVA ≤0.6 cm², mean gradient ≥50 mmHg, or jet velocity ≥5 m/s) 1, 2
  • Hypotensive response to exercise 1
  • Reduced left ventricular function (EF <50%) 1

Other Indications

• Severe AS in patients undergoing CABG, aortic surgery, or other valve surgery (Class I, LOE: C) 1
• Symptomatic moderate AS undergoing CABG, aortic surgery, or other valve surgery (Class IIa, LOE: C) 1

Selection of Intervention Type

Surgical Aortic Valve Replacement (SAVR)

• Traditional standard of care for patients at low surgical risk 2
• Considerations:
  • Lower rate of paravalvular regurgitation compared to TAVR 1
  • Lower pacemaker insertion rates (3%) compared to TAVR 1
  • Better long-term durability data, particularly important for younger patients 3

Transcatheter Aortic Valve Replacement (TAVR)

• Recommended for patients with:
  • Prohibitive surgical risk (≥50% risk of mortality or irreversible morbidity at 30 days) 1, 2
  • High surgical risk (STS score ≥8%) 1, 2
  • Intermediate surgical risk (reasonable alternative to SAVR) 2
  • Special considerations: frailty, prior radiation therapy, porcelain aorta, severe hepatic or pulmonary disease 1

Decision Algorithm

1. Confirm severe AS diagnosis (AVA <1.0 cm², mean gradient >40 mmHg) 1
2. Assess symptom status (dyspnea, angina, syncope)
3. Evaluate surgical risk using validated scores (STS-PROM)
4. Convene Heart Team for decision-making 1
5. Select intervention based on:
   • Patient's surgical risk
   • Anatomical considerations
   • Comorbidities
   • Patient preference
   • Life expectancy (>12 months) 1

Special Clinical Scenarios

Low-Flow, Low-Gradient Aortic Stenosis

• For patients with reduced EF and "low-flow, low-gradient" AS (valve area <1 cm², EF <40%, mean gradient <40 mmHg):
  • Perform low-dose dobutamine stress echocardiography to differentiate true severe AS from pseudo-severe AS 1
  • AVR is recommended for patients with true severe AS and evidence of flow reserve 1
  • Prognosis is better for patients with contractile reserve 1

Very Severe Aortic Stenosis

• AVR is appropriate even in asymptomatic patients with very severe AS (Vmax ≥5 m/s or mean gradient ≥60 mmHg) 2
• The RECOVERY trial demonstrated lower mortality with early AVR in very severe AS 1

Common Pitfalls to Avoid

• Delaying intervention in symptomatic patients, which significantly increases mortality 2
• Failing to recognize reduced left ventricular function, which warrants earlier intervention 2
• Not involving a multidisciplinary Heart Team in decision-making 1, 2
• Overlooking the severity of symptoms in elderly patients due to reduced mobility or comorbidities 1
• Inadequate follow-up of asymptomatic patients (recommended every 6-12 months for severe AS) 4

Outcomes and Complications

• SAVR complications: mortality (3%), stroke (2%), prolonged ventilation (11%), thromboembolism and bleeding 1
• TAVR complications: mortality (3-5%), stroke (6-7%), access complications (17%), pacemaker insertion (2-9% with Sapien, 19-43% with CoreValve), paravalvular regurgitation 1
• TAVR has shown significant reduction in mortality and hospitalization rates compared to medical therapy in inoperable patients at 2 years (43.3% vs 68.0% mortality) 5