What is the treatment for aortic stenosis?

Treatment for Aortic Stenosis

Aortic valve replacement (AVR)—either surgical (SAVR) or transcatheter (TAVR)—is the only effective treatment for symptomatic severe aortic stenosis, and medical management alone is rarely appropriate for these patients. 1, 2

Symptomatic Severe Aortic Stenosis

AVR is appropriate (rated 7-9) for all symptomatic patients with severe aortic stenosis, regardless of surgical risk. 3, 1 The choice between TAVR and SAVR depends on surgical risk stratification by a multidisciplinary Heart Team comprising cardiac surgeons, interventional cardiologists, imaging specialists, and other relevant experts. 1

Risk-Based Treatment Selection:

• High/Extreme Risk (STS-PROM ≥8% or predicted 30-day mortality ≥15%): TAVR is the preferred procedure 1

• Intermediate Risk (STS-PROM 3-10%): Both TAVR and SAVR are appropriate options, with selection based on individual anatomic suitability and patient factors 3, 1

• Low Risk (STS-PROM <3%): SAVR remains the standard of care, though TAVR is increasingly considered 3, 4

Critical Pitfall:

Delaying intervention in symptomatic patients leads to increased mortality—once symptoms develop, average survival without treatment is only 2-3 years. 3, 1 Prompt referral for AVR is essential. 1

Asymptomatic Severe Aortic Stenosis

Watchful waiting is generally appropriate for most asymptomatic patients with preserved left ventricular function and no high-risk features. 3, 4 However, specific subgroups warrant earlier intervention:

AVR is Appropriate in Asymptomatic Patients When:

• Very severe stenosis (Vmax ≥5 m/sec or mean gradient ≥60 mmHg) 1

• Left ventricular ejection fraction <50% despite absence of other causes 3

• Abnormal exercise stress test showing exercise-induced symptoms (angina, excessive dyspnea, syncope), limited exercise capacity, or abnormal blood pressure response 3

• Rapid progression markers present: valve velocity increase >0.3 m/s/year, severe valve calcification, elevated BNP, or excessive LV hypertrophy without hypertension 3

• High-risk profession or lifestyle (airline pilot, competitive athlete) or anticipated prolonged time away from medical supervision 3

AVR May Be Appropriate When:

• Undergoing other cardiac surgery (e.g., CABG) 3
• Vmax 4.0-4.9 m/sec with predictors of rapid progression 3

Low-Flow, Low-Gradient Aortic Stenosis

This represents a diagnostic challenge requiring additional evaluation. 3

Perform low-dose dobutamine stress echocardiography to differentiate true severe AS from pseudosevere AS. 3, 1, 2

• True severe AS with flow reserve: AVR is appropriate 1
• Pseudosevere AS: Medical management is appropriate 2
• Profoundly depressed LV systolic function without contractile reserve: Medical management is appropriate 2

When Medical Management Alone is Appropriate

Medical management without AVR is appropriate only in highly specific circumstances: 2

• Life expectancy <1 year due to comorbidities unrelated to AS 2
• Moderate to severe dementia 2
• Confirmed pseudosevere AS on dobutamine stress testing 2
• Profoundly depressed LV function without contractile reserve 2

Critical Understanding:

No pharmacologic therapy modifies the natural history of severe symptomatic AS or delays progression of degenerative calcific AS. 2 Diuretics and heart failure medications provide only temporary symptomatic relief without changing prognosis. 2

Balloon Aortic Valvuloplasty (BAV)

BAV is not a definitive treatment and should only be considered as: 2

• A palliative measure in patients with life expectancy <1 year or severe dementia 2
• A bridge to decision-making about AVR 3
• Temporizing measure before urgent major noncardiac surgery in symptomatic patients 3

Surveillance for Asymptomatic Patients

Serial Doppler echocardiography is recommended: 4

• Every 6-12 months for severe AS 4
• Every 1-2 years for moderate AS 4
• Every 3-5 years for mild AS 4

Patients must be educated to promptly report any symptoms (dyspnea, angina, syncope, reduced exercise tolerance) to their physicians. 4

Concomitant Valve Disease

• Severe primary mitral regurgitation: Address both valves during intervention when feasible 3
• Secondary mitral regurgitation: May improve with isolated AVR depending on degree of LV dysfunction and mitral leaflet tethering 3
• Severe tricuspid regurgitation: Should be treated whenever possible, as it carries very poor prognosis 3

Special Anatomic Considerations

• Bicuspid aortic valve with ascending aortic aneurysm ≥4.5 cm: Consider combined valve and aortic surgery 3
• LVOT obstruction with septal hypertrophy: Must address both valvular and subvalvular obstruction, as LVOT obstruction may worsen after isolated AVR 3