What are the treatment options for aortic stenosis?

Treatment for Aortic Stenosis

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

Primary Treatment Algorithm

Symptomatic Severe Aortic Stenosis

All patients presenting with dyspnea, heart failure, angina, syncope, or presyncope require valve replacement regardless of surgical risk stratification. 1 The choice between SAVR and TAVR depends on surgical risk and anatomic considerations:

Low-Risk Patients (STS-PROM <3%):

• SAVR is the preferred approach for low-risk patients and those requiring concomitant cardiac surgery (CABG, ascending aorta surgery, or other valve procedures). 1
• SAVR remains the standard treatment for younger patients with longer life expectancy. 2

Intermediate-Risk Patients (STS-PROM 4-8%):

• Either SAVR or TAVR is appropriate, with the choice determined by a multidisciplinary Heart Team based on anatomic factors, patient age, frailty, and comorbidities. 1
• TAVR is a reasonable option for intermediate-risk patients. 2

High or Prohibitive-Risk Patients (STS-PROM ≥8%):

• TAVR is the appropriate treatment for high or prohibitive surgical risk patients, including those with frailty, porcelain aorta, hostile chest, or significant comorbidities not captured by scoring systems. 1, 3
• TAVR reduces mortality and hospitalization rates compared to standard therapy in inoperable patients, with sustained benefits at 2 years. 4

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
• 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. 1, 3

Asymptomatic Severe Aortic Stenosis

• Intervention is appropriate for asymptomatic patients with very severe stenosis (Vmax ≥5 m/sec or mean gradient ≥60 mmHg). 2
• Intervention is appropriate for asymptomatic patients with abnormal exercise testing (which reclassifies them as symptomatic). 1, 2
• Intervention is appropriate for asymptomatic patients with LVEF <50%. 2

Patients Requiring Urgent/Elective Major Noncardiac Surgery

• Symptomatic severe AS: Definitive AVR (SAVR or TAVR) before surgery is appropriate; no intervention carries 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 serve 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 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

Medical Management: Limited Role

Medical management is appropriate only in highly specific circumstances:

• Life expectancy <1 year where overall health is influenced more by comorbidities than aortic stenosis. 3
• Moderate to severe dementia. 3
• Pseudosevere stenosis identified by dobutamine stress testing. 3
• Profoundly deteriorated LV systolic dysfunction without contractile reserve. 3

Critical caveat: Medical management does not modify the natural history of severe symptomatic aortic stenosis, and no pharmacologic therapy delays progression of degenerative calcific aortic stenosis. 3 Diuretics and heart failure medications provide only temporary symptomatic relief without changing prognosis. 3

Balloon Aortic Valvuloplasty as Palliative Option

• BAV may be considered only as a palliative measure in patients with life expectancy <1 year or moderate to severe dementia. 3
• BAV can serve as a bridge to valve replacement in select cases. 2

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, 2 The initial procedure selection has critical implications for lifetime management, as many patients may require 2-3 interventions during their lifetime given the durability limitations of bioprosthetic valves. 5

Common Pitfalls to Avoid

• Do not delay intervention in symptomatic patients, as this leads to increased mortality. 1, 3
• Do not rely on medical management alone for symptomatic severe aortic stenosis, as it does not alter natural history. 3
• Be aware that TAVR carries higher stroke risk compared to standard therapy (13.8% vs. 5.5%), particularly ischemic events in the first 30 days. 4
• Recognize that extensive coexisting conditions may attenuate the survival benefit of TAVR. 4
• Consider that TAVR has unresolved issues including durability, conduction system disorders, and coronary reaccess that are particularly relevant in younger, lower-risk patients. 6