What is the recommended treatment for aortic stenosis?

Treatment of Aortic Stenosis

Aortic valve replacement (AVR)—either surgical (SAVR) or transcatheter (TAVR)—is the definitive treatment for symptomatic severe aortic stenosis and is appropriate for most patients regardless of surgical risk, as it is the only intervention proven to improve survival. 1

Symptomatic Severe Aortic Stenosis

For symptomatic patients with severe AS, AVR is appropriate and medical management alone is rarely appropriate. 1 The presence of symptoms (angina, syncope, heart failure) with severe AS carries a dismal prognosis with average survival of only 2-3 years without intervention. 1

Treatment Selection by Surgical Risk:

• Low surgical risk (STS-PROM <3%): SAVR is appropriate 1
• Intermediate surgical risk (STS-PROM 3-10%): Both SAVR and TAVR are appropriate 1
• High surgical risk or prohibitive risk: TAVR is appropriate 1, 2
• Patients with frailty, porcelain aorta, hostile chest, or significant comorbidities (lung/liver disease, malignancy): TAVR is preferred over SAVR 1

Exception—Medical Management Appropriate:

Medical management (without AVR) is appropriate only when life expectancy is <1 year from comorbidities or in patients with moderate-to-severe dementia, where balloon valvuloplasty may be appropriate for palliation. 1

Asymptomatic Severe Aortic Stenosis

The management of asymptomatic patients is more nuanced and depends on specific clinical and echocardiographic features. 1, 3

AVR is Appropriate in Asymptomatic Patients When:

• LVEF <50%: AVR is appropriate regardless of surgical risk 1
• Abnormal exercise stress test (exercise-induced symptoms, limited exercise capacity, abnormal BP response, or mean gradient increase ≥18 mmHg): AVR is appropriate regardless of surgical risk 1
• Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg): AVR is appropriate, particularly with low surgical risk 1
• Undergoing other cardiac surgery: AVR is appropriate and failure to intervene is rarely appropriate 1

AVR May Be Appropriate in Asymptomatic Patients When:

• Normal exercise stress test BUT ≥1 predictor of rapid progression (ΔVmax >0.3 m/s/year, severe valve calcification, elevated BNP, excessive LV hypertrophy without hypertension): AVR is appropriate especially with low surgical risk, while medical management may be appropriate 1
• High-risk profession (airline pilot) or competitive athlete or prolonged time away from medical supervision: AVR is appropriate with low surgical risk 1

Medical Management is Appropriate in Asymptomatic Patients When:

• LVEF ≥50%, Vmax 4.0-4.9 m/sec, negative exercise stress test, NO predictors of rapid progression: Medical management is appropriate with serial monitoring 1

Low-Flow, Low-Gradient Aortic Stenosis

This challenging subset requires additional testing to distinguish truly severe AS from pseudosevere AS. 1

With Reduced EF (LVEF 20-49%):

• Dobutamine stress echo shows flow reserve AND confirms truly severe AS: AVR is appropriate regardless of surgical risk 1
• No flow reserve BUT very calcified valve on echo/CT suggesting truly severe AS: AVR is appropriate, though medical management may be appropriate with high/intermediate surgical risk 1
• Minimal valve calcification on echo/CT: Medical management is appropriate; AVR is rarely appropriate 1
• Pseudosevere AS confirmed: Medical management is appropriate; AVR is rarely appropriate 1

With Profoundly Reduced EF (LVEF <20%):

Medical management may be appropriate as a bridge to decision, with careful assessment of contractile reserve. 1

Concomitant Coronary Artery Disease

When severe AS coexists with significant CAD, combined SAVR + CABG is appropriate. 1 For intermediate/high surgical risk patients with less complex coronary disease (lower SYNTAX score), catheter-based approaches may be appropriate. 1

Monitoring Asymptomatic Patients

Serial Doppler echocardiography is essential: 2

• Severe AS: Every 6-12 months
• Moderate AS: Every 1-2 years
• Mild AS: Every 3-5 years

Patients must be educated to report symptoms immediately, as survival decreases rapidly once symptoms develop. 2

Common Pitfalls

• Failing to perform exercise stress testing in asymptomatic patients who can exercise—this identifies occult symptoms and guides timing of intervention 1
• Delaying intervention in symptomatic patients due to advanced age or comorbidities—TAVR has expanded treatment options for high-risk patients 1, 2
• Not distinguishing truly severe from pseudosevere AS in low-flow, low-gradient scenarios—dobutamine stress echo and valve calcification assessment are critical 1
• Assuming medical therapy can halt progression—no medical therapy (statins, ACE inhibitors, anticalcific agents) has been proven to slow AS progression or improve outcomes 4