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

Management of Severe Aortic Stenosis with Reduced Ejection Fraction in a 60-Year-Old Patient

Aortic valve replacement (AVR) is the definitive management for this patient, with the choice between surgical AVR (SAVR) or transcatheter AVR (TAVR) determined by surgical risk assessment—SAVR is strongly preferred for low-risk patients in their 60s, while TAVR is appropriate for high or intermediate surgical risk. 1

Intervention is Mandatory

• Valve replacement is appropriate (appropriateness score 8-9) for all patients with severe aortic stenosis and reduced ejection fraction (<50%), regardless of surgical risk. 2, 1
• Medical management alone or follow-up with echocardiography is rarely appropriate (appropriateness score 1-2) and should not be pursued. 2, 1
• The presence of reduced LVEF eliminates any need for stress testing to inform decision-making—the reduced ejection fraction alone mandates intervention. 2, 1

Selecting Between Mechanical, SAVR, and TAVR

For Low Surgical Risk (STS-PROM ≤8%)

• SAVR is strongly preferred over TAVR for patients in their 60s with low surgical risk (appropriateness score 9). 1
• For patients aged 65-75 years, SAVR is generally preferred over TAVR, though both are acceptable depending on comorbidities. 1
• Mechanical valve replacement can be considered in younger patients (<65 years) with longer life expectancy requiring valve durability, though this requires lifelong anticoagulation. 1

For High or Intermediate Surgical Risk (STS-PROM >8%)

• Both TAVR and SAVR are appropriate options (appropriateness score 8) when surgical risk is elevated. 2, 1
• TAVR is the preferred procedure for patients with high or extreme surgical risk (STS-PROM ≥8% or 30-day mortality risk ≥15%). 3, 4
• TAVR has demonstrated sustained mortality benefit at 2 years compared to standard therapy in high-risk patients (43.3% vs 68.0% mortality, P<0.001). 4

Critical Risk Assessment Algorithm

Calculate the STS-PROM score first to guide the approach:

• STS-PROM ≤8%: SAVR is preferred 1
• STS-PROM >8%: TAVR is preferred 1

Additional factors favoring TAVR despite lower risk scores include: 1

• Frailty
• Porcelain aorta
• Hostile chest from prior surgery
• Significant comorbidities limiting life expectancy

Factors favoring SAVR include: 1

• Younger age (<65 years) where mechanical valve may be considered
• Longer life expectancy requiring valve durability
• Potential need for future reintervention

Special Considerations for Low-Flow, Low-Gradient AS

• If the patient presents with low-flow, low-gradient aortic stenosis (which can occur with reduced LVEF), dobutamine stress echocardiography must be performed to distinguish true-severe from pseudo-severe AS. 2, 1, 3
• If flow reserve is present on dobutamine and confirms truly severe AS, AVR is appropriate regardless of surgical risk (appropriateness score 8-9). 2, 1
• If no flow reserve exists but the valve shows heavy calcification on echo/CT suggesting truly severe AS, AVR remains appropriate (appropriateness score 7) with high or intermediate surgical risk. 2, 1
• If minimal calcification is present on echo/CT with no flow reserve, medical management may be appropriate (appropriateness score 7 for no intervention) with high or intermediate surgical risk. 2

Mandatory Heart Team Evaluation

• All decisions regarding valve replacement must involve a multidisciplinary heart team assessment, including cardiologists, cardiac surgeons, and imaging specialists. 1, 3
• TAVR should only be performed in hospitals with cardiac surgery on-site. 1
• Life expectancy must exceed 1 year for TAVR to be appropriate. 1

Common Pitfalls to Avoid

• Do not delay intervention in patients with reduced LVEF—even asymptomatic patients with LVEF <50% require prompt AVR. 2, 3
• Do not misdiagnose low-flow, low-gradient AS as pseudo-severe disease without performing dobutamine stress echo. 2, 1
• Do not overlook that TAVR carries higher stroke risk (13.8% vs 5.5%, P=0.01) compared to medical management, particularly ischemic events in the first 30 days. 4
• Recognize that extensive coexisting conditions may attenuate the survival benefit of TAVR. 4
• For patients with LVEF <20%, AVR remains appropriate but carries higher risk and requires careful patient selection. 2