What are the treatment options for aortic stenosis?

Treatment of Aortic Stenosis

For symptomatic severe aortic stenosis, aortic valve replacement (either SAVR or TAVR) is the definitive treatment and is appropriate regardless of surgical risk, as medical management does not alter the natural history and delays lead to increased mortality. 1, 2

Primary Treatment Decision Algorithm

Symptomatic Patients with Severe Aortic Stenosis

Valve replacement is appropriate for all symptomatic patients presenting with dyspnea, heart failure, angina, syncope, or presyncope, regardless of surgical risk stratification. 1, 3

• SAVR is preferred for low-risk patients (STS-PROM <3%) and those requiring concomitant cardiac surgery (CABG, ascending aorta surgery, or other valve procedures). 1, 3

• TAVR is appropriate for high or prohibitive surgical risk patients (STS-PROM ≥8% or prohibitive risk factors not captured by scoring systems). 1, 4

• Either SAVR or TAVR is appropriate for intermediate-risk patients (STS-PROM 4-8%), with the choice determined by the Heart Team based on anatomic factors, patient age, frailty, and comorbidities. 1, 5

• TAVR is specifically indicated in patients with frailty, porcelain aorta, hostile chest, or significant comorbidities that increase surgical risk beyond STS-PROM calculations. 2

Asymptomatic Patients with Severe Aortic Stenosis

Intervention is appropriate in the following specific scenarios:

• Very severe stenosis with peak velocity ≥5 m/sec or mean gradient ≥60 mmHg. 1, 3

• Abnormal exercise stress test showing exercise-induced symptoms (angina, excessive dyspnea, dizziness, syncope), limited exercise capacity, abnormal blood pressure response, or mean gradient increase ≥18 mmHg with exercise. 1, 3

• Left ventricular systolic dysfunction with LVEF <50% attributable to aortic stenosis. 1, 3

• Asymptomatic patients requiring elective major noncardiac surgery where AVR is appropriate to reduce perioperative risk. 1

Special Clinical Scenarios

Low-Flow, Low-Gradient Aortic Stenosis with Reduced LVEF

• Dobutamine stress echocardiography is essential to distinguish true severe stenosis from pseudosevere stenosis. 1, 2

• Intervention is appropriate if true severe stenosis is confirmed (AVA ≤1.0 cm² and Vmax >4 m/sec at any flow rate) and contractile reserve is present. 1

• Medical management is appropriate for pseudosevere stenosis or profound LV dysfunction without contractile reserve. 2

Patients Requiring Urgent/Elective Major Noncardiac Surgery

• Symptomatic severe AS: Definitive AVR (SAVR or TAVR) is appropriate before surgery; no intervention is rarely appropriate due to marked perioperative mortality risk. 1

• Asymptomatic severe AS with elective surgery: AVR is appropriate; conservative management may be appropriate depending on surgical urgency. 1

• Balloon aortic valvuloplasty (BAV) may be appropriate as a temporizing bridge in urgent situations but is rarely appropriate for elective scenarios where definitive treatment is preferable. 1

Failing Bioprosthetic Valves

• Valve-in-valve TAVR has gained FDA approval for symptomatic bioprosthetic valve failure in high-risk patients. 1

• TAVR in bioprostheses ≤19 mm is generally discouraged due to high residual gradients and increased mortality, particularly in non-high-risk cohorts. 1

• Higher (more aortic) valve positioning during valve-in-valve procedures is associated with lower residual gradients and potentially improved survival. 1

When Medical Management is Appropriate

Medical management is only appropriate in highly specific circumstances where intervention would not improve outcomes:

• Life expectancy <1 year where overall health is dominated by comorbidities rather than aortic stenosis. 2

• Moderate to severe dementia where quality of life would not be meaningfully improved. 2

• Pseudosevere stenosis confirmed by dobutamine stress testing. 2

• Profound LV systolic dysfunction without contractile reserve where intervention carries prohibitive risk without benefit. 2

Critical Pitfalls to Avoid

• No pharmacologic therapy exists that modifies the natural history of degenerative calcific aortic stenosis. 2

• Diuretics and heart failure medications provide only temporary symptomatic relief without altering prognosis. 2

• Delaying intervention in symptomatic patients directly increases mortality—untreated symptomatic severe AS has a mean survival of 2-3 years. 2, 3

• BAV is purely palliative and should only be considered as a bridge to decision-making or in patients with life expectancy <1 year who are not candidates for definitive valve replacement. 2

• Exercise stress testing in asymptomatic patients is crucial—a positive test reclassifies the patient as symptomatic, making intervention appropriate regardless of surgical risk. 1, 3

Decision-Making Framework

All treatment decisions should be made by a multidisciplinary Heart Team comprising cardiac surgeons, interventional cardiologists, cardiac imaging specialists, anesthesiologists, and geriatricians. 1, 3 Complex procedures or interventions in asymptomatic patients should be performed at centers with appropriate expertise to minimize complications. 1