What is the best course of treatment for severe aortic stenosis?

Treatment of Severe Aortic Stenosis

Aortic valve replacement (AVR)—either transcatheter (TAVR) or surgical (SAVR)—is the definitive treatment for severe symptomatic aortic stenosis and should be performed promptly, as medical management alone is associated with dramatically worse survival and is rated "Rarely Appropriate." 1, 2

Symptomatic Patients: Immediate Intervention Required

For all patients with symptomatic severe aortic stenosis (heart failure, angina, or syncope), AVR is rated "Appropriate" regardless of surgical risk level. 1, 2 Delaying intervention leads to mortality rates of 50-60% at 2 years in high-risk patients and 3-year survival rates below 30% without surgery. 3, 4

Surgical Risk-Based Algorithm for Symptomatic Patients:

• High or prohibitive surgical risk (STS-PROM ≥8% or 30-day mortality risk ≥15%): TAVR is the preferred procedure 1, 2

• Intermediate surgical risk (STS-PROM 3-10%): Both TAVR and SAVR are appropriate options; decision should be made by a multidisciplinary Heart Team considering patient anatomy, frailty, comorbidities, and patient preference 1, 2

• Low surgical risk (STS-PROM <3%): SAVR is preferred, though TAVR is a reasonable alternative in selected patients after Heart Team evaluation 2

Special Anatomical Considerations Favoring TAVR:

• Porcelain aorta or hostile chest anatomy 2
• Prior cardiac surgery with patent grafts at risk during reoperation 2
• Frailty or significant comorbidities not captured by STS-PROM 5

Asymptomatic Patients: Selective Intervention Based on High-Risk Features

While watchful waiting is generally appropriate for truly asymptomatic patients, certain high-risk features mandate intervention even without symptoms:

Class I Indications for AVR in Asymptomatic Patients:

• Reduced left ventricular ejection fraction (<50%) without another cause: AVR is "Appropriate" regardless of surgical risk 6, 2

• Very severe aortic stenosis (Vmax ≥5 m/sec or mean gradient ≥60 mmHg): AVR is "Appropriate" when operative mortality is <1%, as these patients are at increased risk for death and rapid symptom development 6, 1, 2

Additional Predictors of Rapid Progression (AVR "May Be Appropriate"):

• Vmax increase >0.3 m/s per year 2
• Severe valve calcification on echocardiography or CT 2
• Elevated BNP levels 2
• Excessive LV hypertrophy without hypertension 2
• Abnormal exercise stress test (considered a surrogate for symptomatic status, making AVR "Appropriate") 6, 2

Low-Flow, Low-Gradient Aortic Stenosis: Critical Diagnostic Step

In patients with reduced LVEF (20-49%), low flow, and low gradient, perform low-dose dobutamine stress echocardiography to differentiate true-severe from pseudo-severe aortic stenosis. 1, 2

• If flow reserve is present and truly severe AS is confirmed: AVR is "Appropriate" 6, 1
• If pseudo-severe AS is identified: Medical management is "Appropriate" and AVR is "Rarely Appropriate" 6, 5
• If no flow reserve and very calcified valve on echo/CT suggesting truly severe AS: AVR is "Appropriate" (score 7), though medical management "May Be Appropriate" (score 4-5) 6

Patients Requiring Major Noncardiac Surgery

Symptomatic Severe AS:

• No intervention prior to surgery is "Rarely Appropriate" due to marked increase in perioperative morbidity/mortality 6
• Definitive AVR (TAVR or SAVR) is "Appropriate" 6
• Balloon valvuloplasty "May Be Appropriate" as temporizing measure 6

Asymptomatic Severe AS:

• For elective surgery: AVR is "Appropriate"; no intervention "May Be Appropriate" 6
• For urgent surgery: All options (no intervention, BAV, or AVR) "May Be Appropriate" depending on individual circumstances 6

Limited Role for Medical Management

Medical management is only "Appropriate" in highly specific circumstances: 5

• Life expectancy <1 year where comorbidities (not AS) dominate prognosis 5
• Moderate to severe dementia 5
• Confirmed pseudo-severe AS on dobutamine stress echo 5
• Profoundly impaired LV systolic dysfunction without contractile reserve 5

Critical caveat: No pharmacologic therapy (including statins, antihypertensives, or anticalcific agents) has been shown to slow AS progression or improve outcomes. 2, 7 Medical management provides only temporary symptomatic relief without changing prognosis. 5

Balloon Aortic Valvuloplasty: Palliative Only

Balloon valvuloplasty is "Rarely Appropriate" as definitive therapy and should only be considered "May Be Appropriate" as a palliative bridge in patients with life expectancy <1 year or severe dementia who are not AVR candidates. 6, 5

Critical Pitfalls to Avoid

• Delaying intervention in symptomatic patients: This is the most common and deadly error, as observational data show poor survival without AVR 2, 4. Real-world data reveals substantial clinician variability in AVR rates (0-100% among cardiologists), with patients treated by low-AVR-rate cardiologists experiencing 22% higher 1-year mortality. 4

• Overlooking reduced LVEF: Even asymptomatic patients with LVEF <50% due to AS require AVR 2

• Failing to recognize very severe AS: Patients with Vmax ≥5 m/sec or mean gradient ≥60 mmHg are at higher risk for adverse outcomes and warrant intervention even when asymptomatic 1

• Not distinguishing true-severe from pseudo-severe AS: Always perform dobutamine stress echo in low-flow, low-gradient scenarios before committing to AVR 1, 2

• Bypassing Heart Team evaluation: The decision between TAVR and SAVR requires input from cardiologists, cardiac surgeons, imaging specialists, and other relevant specialists 1, 2