What is the management approach for a patient with aortic stenosis and heart failure?

Management of Aortic Stenosis with Heart Failure

Immediate Priority: Valve Replacement

All symptomatic patients with severe aortic stenosis and heart failure require urgent aortic valve replacement (AVR), as this is the only treatment that improves survival and reduces mortality. 1, 2 Medical therapy for heart failure is reserved only for non-operable patients and should not delay surgical decision-making. 1

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Confirming True Severe Aortic Stenosis

The Low-Flow, Low-Gradient Challenge

When heart failure coexists with aortic stenosis, you must differentiate true severe stenosis from pseudo-stenosis (where low cardiac output falsely suggests severe disease): 1

• Perform low-dose dobutamine stress echocardiography in patients with valve area <1 cm², LVEF <40%, and mean gradient <40 mmHg 1
• This test identifies contractile reserve and confirms whether the stenosis is truly severe or only appears severe due to low flow 1, 3
• If mean gradient rises >40 mmHg with dobutamine, proceed to AVR regardless of baseline LVEF—there is no lower ejection fraction limit for valve replacement in true severe stenosis 1
• Patients with contractile reserve have lower operative mortality and better long-term outcomes 1
• Even patients without contractile reserve may be considered for surgery, though with higher risk 1

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Choosing Between SAVR and TAVR

Risk-Based Algorithm

High surgical risk patients (STS-PROM >8%) or those deemed inoperable by the Heart Valve Team should undergo TAVR 1, 2:

• TAVR is recommended (Class I) for patients not suitable for surgery with predicted post-TAVR survival >1 year 1
• TAVR should be considered (Class IIa) for high-risk patients who may still be suitable for surgery 1

Low to moderate surgical risk patients should undergo surgical AVR 2, 4:

• Particularly in younger patients where valve durability is critical 2
• Surgical AVR remains the standard of care for most patients 4

The Heart Valve Team must make this decision incorporating cardiologists, cardiac surgeons, imaging specialists, and anesthesiologists 1, 2

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Pre-Procedural Essentials

Mandatory Workup

Coronary angiography is required in all patients being considered for AVR, as 40-75% have concurrent coronary artery disease 1, 2:

• The Heart Valve Team decides on a case-by-case basis whether to revascularize before AVR 1
• For severe multivessel or left main disease, combined SAVR + CABG is appropriate 1, 2

Baseline assessment must include 1, 2, 5:

• Physical examination, ECG, complete blood count, basic metabolic profile, coagulation studies
• Troponin and BNP levels
• Chest radiograph and pulmonary function tests
• Documentation of contrast/latex allergies
• Dental evaluation to prevent prosthetic valve endocarditis
• Assessment of social support for post-procedure recovery

Echocardiography must evaluate 1, 2:

• LV systolic and diastolic function
• Severity of concurrent mitral regurgitation or stenosis
• Pulmonary artery pressures

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Medical Management: Bridging to Surgery

Critical Hemodynamic Principles

Medical therapy does NOT alter disease progression or improve outcomes—it only stabilizes patients until definitive valve replacement 1, 5:

Heart rate control is essential 2, 5:

• Both bradycardia and tachycardia cause clinical decompensation 2, 5
• Target normal sinus rhythm with adequate diastolic filling time 2

Fluid management requires careful balance 2, 5:

• Maintain adequate preload without volume overload 2
• These patients are preload-dependent due to LV hypertrophy and diastolic dysfunction 5

Blood pressure management must be cautious 1, 2:

• Target systolic BP 100-120 mmHg in acute settings 2
• Vasodilators (ACE inhibitors, ARBs, hydralazine, nitrates) may cause profound hypotension and should be used with extreme caution 1
• Beta-blockers are preferred for BP control as they reduce LV ejection force 2
• Calcium channel blockers may be considered in patients with pulmonary disease 2

For hypotensive patients 5:

• Use vasopressors at the lowest effective dose 5
• Dobutamine can increase inotropy in low-output states 5

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Special Considerations

Concurrent Mitral Stenosis

If significant mitral stenosis (valve area <1.5 cm²) coexists, address both valves during the same procedure 6:

• AVR will reduce LV afterload, creating hyperdynamic LV function that increases flow across the stenotic mitral valve 6
• This worsens transmitral gradients, left atrial pressure, and pulmonary hypertension 6
• In symptomatic patients or those with PA pressure >50 mmHg, correct mitral stenosis before or simultaneously with AVR 6

Life Expectancy <1 Year

Do not proceed with AVR if life expectancy is <1 year or severe dementia is present—this represents medical futility 1, 2:

• Consider palliative balloon aortic valvuloplasty as a temporizing measure in select cases 2, 5
• Discuss palliative care options with patient and family 1

Asymptomatic Patients

Exercise testing can unmask symptoms in apparently asymptomatic patients, particularly elderly patients with reduced mobility or multiple comorbidities 1, 2:

• Surgery is indicated if symptoms develop during exercise testing 1
• Surgery should be considered if blood pressure falls below baseline during exercise 1

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Common Pitfalls to Avoid

Do not delay surgery for medical optimization—symptomatic patients require urgent intervention 1:

• Average survival drops to 2-3 years once symptoms develop 2
• Medical therapy does not retard AS progression 1

Do not assume all low-gradient AS is severe—always perform dobutamine stress echo to confirm true stenosis 1, 3

Do not aggressively treat hypertension with vasodilators—these patients are afterload-dependent and may decompensate with hypotension 1

Do not underestimate concurrent valve disease—particularly mitral stenosis, which can worsen dramatically after AVR 6

Do not proceed with AVR without coronary angiography—missing significant CAD leads to worse outcomes 1, 2

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Post-Procedural Monitoring

Close follow-up is mandatory after AVR 1, 7:

• Monitor for persistence or worsening of heart failure symptoms 7
• Advanced cardiac damage, concomitant conditions, and procedure-related factors may contribute to ongoing HF 7
• Multidisciplinary management involving an HF specialist is crucial 7
• Serial echocardiography to assess valve function, LV recovery, and concurrent valve disease 1, 6