Treatment of Severe Aortic Valve Stenosis
Aortic valve replacement (either surgical or transcatheter) is the definitive treatment for severe symptomatic aortic stenosis, as there is no effective medical therapy and untreated symptomatic disease carries a mortality rate of approximately 50% within 2 years of symptom onset. 1, 2
Symptomatic Severe Aortic Stenosis
High-Gradient Severe AS
- Aortic valve replacement is indicated (Class I) for all symptomatic patients with severe high-gradient AS presenting with dyspnea, heart failure, angina, syncope, or presyncope. 3, 1
- Symptoms define the need for intervention regardless of left ventricular ejection fraction, provided the mean gradient is >40 mmHg. 3
Low-Flow Low-Gradient AS with Reduced LVEF
- Intervention is recommended (Class I) for symptomatic patients with low-flow low-gradient severe AS and reduced LVEF (<40%). 3, 1
- Low-dose dobutamine stress echocardiography should be performed (Class IIa) to distinguish true-severe from pseudo-severe AS and assess contractile reserve. 3, 1
- If the mean gradient increases to >40 mmHg with dobutamine, there is theoretically no lower LVEF limit for valve replacement. 3
- Medical management is appropriate only when stress testing suggests pseudo-severe stenosis or profoundly impaired LV function without contractile reserve. 3
Low-Flow Low-Gradient AS with Preserved LVEF
- Intervention should be considered after meticulous confirmation of stenosis severity through comprehensive echocardiographic assessment. 1
Asymptomatic Severe Aortic Stenosis
Intervention is appropriate in specific high-risk asymptomatic patients: 1
- Very severe AS with Vmax ≥5 m/sec or mean gradient ≥60 mmHg 3, 1
- Abnormal exercise stress test (which effectively identifies the patient as symptomatic) 3, 1
- LVEF <50% (ACC/AHA) or <55% (ESC/EACTS) without another cause 3, 1
Choice Between SAVR and TAVR
SAVR is Preferred For:
- Patients <65 years of age 3
- Low surgical risk (STS-PROM <8%) 3
- Need for concomitant cardiac surgery (CABG, ascending aorta surgery, other valve surgery) 1, 4
- Small surgical bioprosthesis size (≤19 mm) where valve-in-valve TAVR would result in high residual gradients 3
TAVR is Preferred For:
- Patients >80 years of age 3
- High or prohibitive surgical risk (Class I recommendation) 3, 1
- Intermediate surgical risk (reasonable option) 1
- Frailty or factors not captured by STS-PROM (porcelain aorta, hostile chest) 3, 1
- Significant comorbidities including lung disease, liver disease, or malignancy 3, 1
- Predicted post-TAVR survival >1 year 3
Age 65-80 Years:
- Either SAVR or TAVR is appropriate, with decision based on surgical risk, anatomy, comorbidities, and frailty 3
- All decisions should be made by a multidisciplinary Heart Team including cardiologists, cardiac surgeons, and heart failure specialists 1, 4
Special Circumstances
Patients Requiring Major Non-Cardiac Surgery:
- AVR (TAVR or SAVR) is appropriate for symptomatic patients or those undergoing elective non-cardiac surgery. 3
- TAVR can be performed as a bridge to non-cardiac surgery, typically 32-74 days before the planned procedure. 5
Medical Futility Scenarios:
- Medical management is appropriate when life expectancy is <1 year due to comorbidities or moderate-to-severe dementia. 3
- Palliative balloon aortic valvuloplasty may be appropriate as a bridge to definitive treatment or for palliation in inoperable patients. 3, 1
Critical Pitfalls to Avoid
- Never rely solely on medical therapy for symptomatic severe AS—without intervention, mortality approximates 2% per month. 2
- Exercise caution with vasodilators (ACE inhibitors, ARBs, CCBs, hydralazine, nitrates) in severe AS to avoid precipitating hypotension. 3
- Do not dismiss asymptomatic patients as low-risk—observational data suggest their natural history is not benign, with 5-year survival of only 38% without intervention. 6
- Ensure symptoms are truly absent through objective exercise testing, as patients may unconsciously limit activity. 7