What is the recommended management for a patient in their 60s with confirmed severe aortic stenosis and reduced ejection fraction?

Management of Severe Aortic Stenosis with Reduced Ejection Fraction in a Patient in Their 60s

For a patient in their 60s with severe aortic stenosis and reduced ejection fraction, surgical aortic valve replacement (SAVR) is the preferred intervention, with transcatheter aortic valve replacement (TAVR) reserved for those with high or intermediate surgical risk. 1

Primary Recommendation Based on Age and Risk Profile

Surgical aortic valve replacement is strongly preferred over TAVR for patients in their 60s with low surgical risk (appropriateness score of 9). 1 The American College of Cardiology guidelines specifically state that for patients aged 65-75 years, SAVR is generally preferred over TAVR, though both are acceptable options depending on surgical risk and comorbidities. 1

The presence of reduced ejection fraction (<50%) makes intervention mandatory regardless of surgical risk, with a Class I recommendation from the American College of Cardiology. 1 Medical management alone is considered rarely appropriate (appropriateness score of 1-2) for patients with severe aortic stenosis and reduced ejection fraction. 1

Risk Stratification Algorithm

Calculate the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score to determine the optimal approach: 2, 1

• STS-PROM <4% (Low Risk): SAVR is strongly preferred 1
• STS-PROM 4-8% (Intermediate Risk): Both SAVR and TAVR are appropriate (appropriateness score of 8), with choice based on additional factors 1, 3
• STS-PROM >8% (High Risk): TAVR is preferred 1

Factors Favoring TAVR Despite Lower Surgical Risk

Even in younger patients with lower calculated surgical risk, TAVR may be appropriate if the following are present: 1

• Frailty (assess using validated frailty indices)
• Porcelain aorta
• Hostile chest from prior cardiac surgery
• Significant comorbidities affecting surgical candidacy
• Major organ system dysfunction

Factors Favoring SAVR

SAVR should be strongly considered when: 1

• Longer life expectancy requiring valve durability
• Potential need for future reintervention
• Age <65 years where mechanical valve may be considered for lifetime durability
• Low surgical risk profile (STS-PROM <4%)

Special Considerations for Reduced Ejection Fraction

If the patient presents with low-flow, low-gradient aortic stenosis (mean gradient <40 mmHg despite reduced EF), dobutamine stress echocardiography must be performed to distinguish true-severe from pseudo-severe AS. 2, 1 This is critical because:

• If flow reserve is present on dobutamine and confirms truly severe AS, AVR is appropriate regardless of surgical risk (appropriateness score of 8-9) 1
• If no flow reserve but the valve is heavily calcified on echo/CT suggesting truly severe AS, AVR is still appropriate (appropriateness score of 7) with high or intermediate surgical risk 1

Research data demonstrates that TAVI patients with reduced LVEF have better recovery of ejection fraction compared to SAVR patients (ΔLVEF 14±15% versus 7±11%), with 58% of TAVI patients achieving normalization of LVEF at 1 year versus 20% in the SAVR group. 4 However, this should not override the age-based preference for SAVR in low-risk patients in their 60s.

Mandatory Heart Team Evaluation

All decisions regarding valve replacement must involve a multidisciplinary Heart Team assessment. 2, 1, 5 This team should include:

• Cardiac surgeons
• Interventional cardiologists
• Cardiac imaging specialists
• Anesthesiologists
• Geriatrics specialists (when appropriate)

The Heart Team evaluates individual patient risks, technical suitability, vascular access issues, and life expectancy. 2, 1

Critical Contraindications and Caveats

For TAVR consideration, the following are relative contraindications: 1

• LVEF <20%
• Bicuspid aortic valve
• Untreated coronary artery disease requiring revascularization
• Life expectancy <1 year

TAVR should only be performed in hospitals with cardiac surgery on-site. 1

Outcome Data Supporting Intervention

The PARTNER 2 trial demonstrated that in intermediate-risk patients, TAVR was non-inferior to SAVR with respect to death or disabling stroke at 2 years (19.3% vs 21.1%). 3 However, TAVR resulted in more paravalvular regurgitation while SAVR resulted in fewer major vascular complications. 3

For inoperable patients, TAVR reduced mortality compared to standard therapy (43.3% vs 68.0% at 2 years), though stroke rates were higher with TAVR (13.8% vs 5.5%). 6

Common Pitfalls to Avoid

Do not delay intervention in symptomatic patients with reduced ejection fraction—prompt referral for AVR is essential as mortality increases significantly with conservative management. 5 The presence of reduced LVEF eliminates the need for stress testing to inform decision-making, and intervention is appropriate based on the reduced ejection fraction alone. 1

Do not assume that reduced ejection fraction is solely due to cardiomyopathy—afterload mismatch from severe AS is often reversible with valve replacement. 4, 7

Do not choose TAVR over SAVR in a low-risk patient in their 60s simply because of reduced ejection fraction—age and surgical risk remain the primary determinants of valve type selection. 1