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

Management of Severe Aortic Stenosis with Reduced Ejection Fraction

For a patient with severe aortic stenosis and reduced ejection fraction, aortic valve replacement (either TAVR or SAVR) is appropriate regardless of surgical risk, and medical management alone is rarely appropriate. 1, 2

Immediate Decision: Intervention is Mandatory

The presence of reduced ejection fraction (<50%) with severe aortic stenosis carries a Class I recommendation for intervention regardless of surgical risk. 1, 2 Medical management alone receives an appropriateness score of only 1-2 (rarely appropriate), making it essentially contraindicated. 1, 2

The reduced ejection fraction eliminates any need for stress testing to inform decision-making—the indication for intervention is established by the reduced LVEF alone. 2

Choosing Between TAVR vs. SAVR: Age is the Primary Determinant

Since the patient's age is uncertain, this becomes the critical factor in selecting the intervention type:

If Patient is Under 65 Years Old:

• SAVR is strongly preferred over TAVR (appropriateness score of 9 for SAVR in low surgical risk patients in their 60s). 2
• Consider mechanical valve if patient is young enough and has no contraindications to anticoagulation. 1, 2
• SAVR provides superior long-term durability and avoids future valve-in-valve procedures. 2

If Patient is 65-75 Years Old:

• SAVR is generally preferred, but both SAVR and TAVR are acceptable options. 1, 2
• Calculate the STS-PROM score: SAVR is preferred for STS-PROM ≤8%, while TAVR is preferred for STS-PROM >8%. 2
• Use bioprosthetic valve (European guidelines recommend surgical bioprosthesis at ≥65 years). 1

If Patient is Over 75 Years Old:

• TAVR becomes increasingly appropriate, particularly if surgical risk is intermediate or high. 2
• Both TAVR and SAVR receive appropriateness scores of 8 for high or intermediate surgical risk. 1, 2

Special Considerations for Low-Flow, Low-Gradient AS

If the patient has low-flow, low-gradient aortic stenosis (which commonly occurs with reduced LVEF):

• Perform dobutamine stress echocardiography to distinguish true-severe from pseudo-severe AS. 1, 2, 3
• If flow reserve is present on dobutamine and confirms truly severe AS, AVR is appropriate (score 8-9). 1, 2
• If no flow reserve but the valve shows heavy calcification on echo/CT suggesting truly severe AS, AVR remains appropriate (score 7) with high or intermediate surgical risk. 1, 2
• If minimal calcification and no flow reserve, intervention becomes less clear (score 3-4 for no intervention). 1

Factors Favoring TAVR Despite Lower Age:

• Frailty or significant comorbidities 2
• Porcelain aorta or hostile chest 2
• Prior cardiac surgery 2
• High surgical risk (STS-PROM >8%) 2

Factors Favoring SAVR Despite Higher Age:

• Longer life expectancy requiring valve durability 2
• Younger age (<65 years) where mechanical valve may be considered 1, 2
• Low surgical risk (STS-PROM ≤8%) 2
• Bicuspid aortic valve (relative contraindication for TAVR) 2, 4

Critical Contraindications and Warnings

If LVEF is <20%, this represents a relative contraindication for TAVR and requires careful consideration. 2 The appropriateness score for AVR drops to 7 with LVEF <20%, though intervention may still be appropriate with intermediate or high surgical risk. 1

Mandatory Requirements for TAVR:

• Multidisciplinary heart team evaluation 2, 3
• Cardiac surgery availability on-site 2
• Life expectancy exceeding 1 year 2
• Evaluation for untreated coronary artery disease requiring revascularization 2

Expected Outcomes

TAVR demonstrates superior LVEF recovery compared to SAVR in patients with reduced ejection fraction. 5 In one study, 58% of TAVR patients achieved LVEF normalization (>50%) at 1 year versus only 20% in the SAVR group, with mean LVEF improvement of 14% vs. 7%. 5

Historical data shows that even with severely reduced LVEF (mean 0.37), surgical AVR produces dramatic improvement in ejection fraction (to 0.63) with 74% three-year survival. 6 This reinforces that intervention should not be withheld based on reduced ejection fraction alone. 6, 7