How to proceed with aortic valve replacement in a patient with severe valvular aortic stenosis, atrial fibrillation, and left ventricular hypertrophy?

Proceed with Scheduled Aortic Valve Replacement Surgery

This patient has a clear Class I indication for aortic valve replacement and should proceed with the scheduled surgery as planned. 1 The patient meets multiple guideline-supported criteria for intervention despite being currently asymptomatic.

Primary Indication: Structural Valve Deterioration

• The patient has severe aortic stenosis in a previously implanted bioprosthetic valve (structural valve failure), which is an absolute indication for intervention regardless of symptoms. 1
• The echo demonstrates severe valvular aortic stenosis with severe aortic thickening in a 25mm bioprosthetic valve implanted during prior SAVR, indicating prosthetic valve degeneration. 1
• Bioprosthetic valve failure requiring reintervention is a Class I indication for valve replacement. 1

Supporting High-Risk Features

The presence of mild concentric LV hypertrophy is a concerning feature that supports early intervention:

• LV hypertrophy in the absence of hypertension history may indicate hemodynamically significant stenosis and is considered a risk factor warranting earlier intervention in asymptomatic patients at low surgical risk. 1
• The EF of 50-55% is at the lower end of normal range, and any decline below 50% would represent LV systolic dysfunction requiring immediate intervention. 1

Atrial Fibrillation Management Considerations

The patient's persistent atrial fibrillation status post-MAZE procedure and LAA ligation requires specific perioperative planning:

• Continue Xarelto anticoagulation management per institutional protocols for perioperative bridging, as the patient has both a mechanical LAA clip and atrial fibrillation. 2
• The history of MAZE procedure and LAA ligation indicates prior attempts at rhythm control, but persistent AF suggests ongoing arrhythmia burden that may complicate postoperative recovery. 3
• Patients with preoperative atrial fibrillation have higher rates of postoperative atrial fibrillation (48% incidence post-AVR), requiring vigilant monitoring. 3

Surgical Approach Decision

Given this is a redo cardiac surgery (prior SAVR with aortic root enlargement), the Heart Valve Team must determine optimal approach:

• Redo surgical AVR (SAVR) versus transcatheter valve-in-valve TAVR should be evaluated by the multidisciplinary Heart Valve Team. 1, 2
• TAVR valve-in-valve is increasingly used for failed bioprosthetic valves and may offer lower perioperative risk in redo scenarios. 2
• The patient's surgical risk profile (STS-PROM score) should guide the choice between redo SAVR and TAVR, with TAVR appropriate if surgical risk is intermediate or high. 1, 2
• The prior aortic root enlargement with bovine pericardial patch adds complexity to redo SAVR but does not preclude either approach. 1

Critical Perioperative Considerations

Specific attention must be paid to:

• Careful hemodynamic monitoring during induction and maintenance of anesthesia, as severe AS patients are at risk for hypotension and cardiovascular collapse. 1, 4
• Maintain adequate preload and avoid tachycardia, particularly given the concurrent atrial fibrillation. 1
• Beta-blocker (metoprolol) should be continued perioperatively for rate control. 1
• The patient's asymptomatic status is favorable but does not eliminate perioperative risk, as symptoms can emerge rapidly with hemodynamic stress. 1, 5

Common Pitfall to Avoid

Do not delay surgery based on the patient's current asymptomatic status. 5 Studies show that physicians commonly underrecognize symptoms in severe AS patients and overestimate operative risk, leading to inappropriate delays in life-saving intervention. 5 This patient has already been appropriately evaluated and scheduled for surgery—proceeding as planned is the correct course of action. 1