What is the recommended management for a patient in their 60s with severe aortic stenosis and reduced ejection fraction?

Management of Severe Aortic Stenosis with Reduced Ejection Fraction in a Patient in Their 60s

This patient requires aortic valve replacement (AVR), and given the age of approximately 60 years with reduced ejection fraction, surgical aortic valve replacement (SAVR) should be the primary approach if surgical risk is low to intermediate, while transcatheter aortic valve replacement (TAVR) is appropriate if surgical risk is high or intermediate. 1

Key Decision Points

Indication for Intervention is Absolute

• Reduced ejection fraction (<50%) with severe aortic stenosis carries a Class I recommendation for intervention regardless of surgical risk. 1
• Medical management is considered rarely appropriate (appropriateness score of 1-2) in this scenario. 1
• The presence of reduced LVEF eliminates the need for stress testing to inform decision-making—intervention is appropriate based on the reduced ejection fraction alone. 1

Age-Based Considerations for Valve Type Selection

For a patient in their 60s, the choice between TAVR and SAVR depends primarily on surgical risk assessment:

• If age is 60-65 years with low surgical risk: SAVR is strongly preferred (appropriateness score of 9 for AVR with low surgical risk). 1
• If age is 65-75 years: SAVR is generally preferred over TAVR, though both are acceptable options depending on surgical risk and comorbidities. 1
• If surgical risk is high or intermediate: Both TAVR and SAVR are appropriate (appropriateness score of 8). 1

Surgical Risk Assessment Determines the Approach

The decision algorithm should proceed as follows:

1. Calculate STS-PROM (Society of Thoracic Surgeons Predicted Risk of Mortality) score: 1

   • STS-PROM >8%: TAVR is preferred 1
   • STS-PROM ≤8%: SAVR is preferred, especially in younger patients 1

2. Evaluate for factors favoring TAVR despite lower surgical risk scores: 1

   • Frailty not captured by STS-PROM
   • Porcelain aorta or hostile chest
   • Significant comorbidities (severe lung disease, liver disease)
   • Prior cardiac surgery

3. Consider factors favoring SAVR in this age group: 1

   • Longer life expectancy requiring valve durability
   • Potential need for future reintervention
   • Younger age (<65 years) where mechanical valve may be considered

Special Considerations for Reduced Ejection Fraction

If this is low-flow, low-gradient aortic stenosis with reduced LVEF, additional evaluation is critical:

• Dobutamine stress echocardiography must be performed to distinguish true-severe from pseudo-severe AS. 1
• If flow reserve is present on dobutamine and confirms truly severe AS: AVR is appropriate regardless of surgical risk (appropriateness score of 8-9). 1
• If no flow reserve but valve is heavily calcified on echo/CT suggesting truly severe AS: AVR is still appropriate (appropriateness score of 7) with high or intermediate surgical risk. 1
• If minimal valve calcification and no flow reserve suggesting pseudo-severe AS: medical management is appropriate (appropriateness score of 7-8 for no intervention). 1

Critical Pitfalls to Avoid

Do not delay intervention based solely on reduced ejection fraction. The reduced LVEF in severe AS often represents afterload mismatch rather than intrinsic myocardial disease, and LVEF typically improves significantly after valve replacement. 2

• Patients with LVEF ≤25% demonstrate substantial recovery post-AVR, with LVEF doubling at two-year follow-up. 2
• Both TAVR and SAVR show similar 30-day mortality (approximately 7%) and similar LVEF recovery in patients with severely reduced ejection fraction. 2
• One week post-procedure, LVEF improves significantly regardless of method (TAVR 33.5% vs SAVR 35.3%, p=0.60). 2

Do not choose TAVR solely based on reduced ejection fraction in a patient in their 60s. Age and surgical risk should drive the decision, not the presence of reduced LVEF alone. 1

Heart Team Evaluation is Mandatory

All decisions regarding TAVR must involve a multidisciplinary heart team assessment. 1

• TAVI should only be performed in hospitals with cardiac surgery on-site. 1
• The heart team should assess individual patient risks, technical suitability, and access issues. 1
• Life expectancy must exceed 1 year for TAVR to be appropriate. 1

Contraindications to Consider

Relative contraindications for TAVR in this patient: 1

• LVEF <20% is a relative contraindication for TAVR 1
• Bicuspid valve (if present) may be a relative contraindication depending on anatomy 1
• Untreated coronary artery disease requiring revascularization 1

Evidence for Mortality Benefit

TAVR demonstrates sustained mortality benefit at 2 years compared to medical therapy in appropriate patients (43.3% vs 68.0% mortality, p<0.001), though stroke risk is higher (13.8% vs 5.5%, p=0.01). 3

The survival benefit of TAVR may be attenuated in patients with extensive coexisting conditions, making careful patient selection critical. 3