What is the recommended management for a patient with severe aortic stenosis (AS) waiting for valve replacement in a hospital setting?

Hospital Management of Severe Aortic Stenosis Awaiting Valve Replacement

Symptomatic patients with severe AS awaiting valve replacement require urgent surgery and should not receive medical therapy for heart failure except in non-operable cases, while asymptomatic patients can be managed with careful hemodynamic monitoring focusing on heart rate control, adequate preload maintenance, and avoidance of hypotension. 1

Immediate Risk Stratification

Upon hospital admission, determine:

• Symptom status: Presence of exertional dyspnea, angina, heart failure, syncope, or presyncope indicates dramatically worse prognosis and mandates urgent intervention 1
• Left ventricular function: LVEF <50% significantly increases perioperative risk and alters management strategy 1
• Severity confirmation: Verify severe AS by echocardiography (aortic valve area <1.0 cm², mean gradient ≥40 mmHg, or peak velocity ≥4.0 m/s) 1, 2

Hemodynamic Management Principles

Critical Monitoring Parameters

Avoid hypotension, excessive hypertension, and tachycardia at all costs 1. The stenotic valve creates fixed cardiac output, making patients extremely sensitive to hemodynamic perturbations.

• Heart rate control: Maintain slower heart rates to prolong diastolic filling time and optimize coronary perfusion 1
• Preload optimization: Maintain adequate preload as these patients are preload-dependent; avoid aggressive diuresis 1, 2
• Afterload management: Avoid vasodilators and positive inotropes as they risk destabilization 1, 2

Specific Hemodynamic Targets

• Blood pressure: Control hypertension cautiously but maintain adequate perfusion pressure 2, 3
• Volume status: Careful fluid management is essential; consider invasive hemodynamic monitoring for high-risk procedures 1
• Rhythm control: Maintain sinus rhythm when possible; atrial contribution to ventricular filling is critical 1

Medical Management While Awaiting Surgery

What NOT to Do

Do not use medical therapy as a substitute for valve replacement in symptomatic patients 1. Medical treatment for heart failure is reserved only for non-operable patients 1.

• Avoid: Aggressive diuretics (risk reducing preload), vasodilators, positive inotropes 1, 2
• Do not use: Statins to prevent AS progression (no proven benefit) 1, 2
• Contraindicated: ACE inhibitors and ARBs in pregnant patients 1

Acceptable Supportive Measures

• Beta-blockers: May be considered for heart rate control, particularly in asymptomatic patients. Metoprolol reduces aortic valve gradients, global afterload, and myocardial oxygen consumption 4
• Cardiovascular risk factor management: Control blood pressure and other risk factors as indicated 1, 2
• Diuretics: Use cautiously only if absolutely necessary for pulmonary congestion, with careful monitoring 1

Bridging Strategies for Urgent Cases

Balloon Aortic Valvuloplasty (BAV)

For patients requiring urgent elevated-risk noncardiac surgery who cannot undergo immediate valve replacement, balloon aortic valvuloplasty may be considered as a bridging strategy 1.

BAV is reasonable for:

• Palliation in patients who cannot undergo surgical AVR due to serious comorbidities 1
• Bridge to surgical AVR in hemodynamically unstable patients 1
• Temporary measure before urgent noncardiac surgery 1

Important caveat: BAV has high restenosis rates and significant complications including mortality (3%), stroke (2%), and hemodynamic instability 1. It provides only temporary relief.

Decision Algorithm for Timing of Valve Replacement

Symptomatic Severe AS

• LVEF <50%: Consider nonsurgical management, minimally invasive alternatives, BAV, palliative care, or proceed with elevated-risk surgery after shared decision-making 1
• LVEF ≥50%: Evaluate for AVR before elective elevated-risk procedures; proceed urgently if symptomatic 1

Asymptomatic Severe AS

• Normal LV function: Can safely undergo elective low-risk procedures with close monitoring 1
• LVEF <50%: Should undergo valve replacement regardless of symptoms 1, 2

Monitoring During Hospitalization

Close monitoring is essential to detect clinical deterioration:

• Serial clinical assessments for symptom development 3
• Continuous telemetry for arrhythmias 1
• Strict intake/output monitoring 1
• Consider transesophageal echocardiography (TEE) monitoring for high-risk situations 1

Common Pitfalls to Avoid

1. Aggressive diuresis: Can precipitate cardiovascular collapse by reducing preload in preload-dependent patients 1, 2
2. Vasodilator use: May cause profound hypotension due to fixed cardiac output 1, 2
3. Delaying surgery in symptomatic patients: Once symptoms develop, prognosis deteriorates rapidly with 30-day mortality of 4.3% in untreated patients versus 0% in those who underwent AVR 1
4. Assuming asymptomatic status is benign: Natural history shows 1,2, and 5-year survival of only 67%, 56%, and 38% respectively in unoperated asymptomatic patients 5

Multidisciplinary Team Involvement

All complex decisions should involve a Heart Team comprising cardiac surgery, interventional cardiology, cardiac imaging, anesthesiology, and geriatrics expertise 2, 6. This team-based approach is foundational for optimal outcomes 1.

The Heart Team should determine:

• Optimal timing of valve replacement 1
• Choice between TAVR versus SAVR based on surgical risk 1, 2
• Management of concurrent conditions 3