What is the recommended treatment for severe aortic stenosis?

Treatment of Severe Aortic Stenosis

Aortic valve replacement (AVR) is the definitive treatment for severe symptomatic aortic stenosis and should be performed promptly, with the choice between transcatheter (TAVR) or surgical (SAVR) approaches determined by surgical risk assessment through a multidisciplinary Heart Team. 1, 2

Symptomatic Patients: Immediate Intervention Required

For all patients with symptomatic severe aortic stenosis, AVR is rated "Appropriate" (score 8-9) regardless of surgical risk, and medical management alone is "Rarely Appropriate" (score 1-3). 1, 2 This applies to patients presenting with:

• Classic symptoms: angina, syncope, dyspnea, or heart failure 1
• Reduced ejection fraction (<50%) with severe AS 1
• Abnormal exercise stress test (which effectively reclassifies "asymptomatic" patients as symptomatic) 1

Critical Exception for Medical Management

Medical management becomes appropriate only when: 1

• Life expectancy is <1 year from comorbidities (not from AS itself)
• Moderate to severe dementia is present
• Overall health status is dominated by comorbidities rather than the aortic stenosis

In these futility scenarios, palliative balloon valvuloplasty may be appropriate as a bridge or for symptom relief. 1

Asymptomatic Patients: Risk Stratification Determines Timing

Class I Indications for Intervention (Even Without Symptoms)

AVR is "Appropriate" (score 8-9) in asymptomatic patients with: 1

1. Reduced LVEF (<50%) - This carries the strongest recommendation regardless of surgical risk 1
2. Abnormal exercise stress test - Positive stress test identifies occult symptoms 1
3. Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg) - Particularly with low surgical risk 1, 2
4. Undergoing other cardiac surgery - AVR is "Appropriate" (score 9) when another cardiac or ascending aortic surgery is planned 1

Predictors of Rapid Progression (Consider Early Intervention)

In asymptomatic patients with preserved LVEF and Vmax 4.0-4.9 m/sec, AVR is "Appropriate" when ≥1 predictor of rapid progression is present: 1, 2

• Rate of velocity progression >0.3 m/sec per year
• Severe valve calcification on echo or CT
• Elevated BNP levels
• Excessive LV hypertrophy without hypertension

Without these predictors and with a normal stress test, medical management is appropriate, though intervention may be appropriate given the relentless progression of severe AS. 1

Surgical Risk-Based Treatment Selection

High/Prohibitive Surgical Risk (STS-PROM ≥8%)

TAVR is the preferred intervention. 2 This includes patients with: 1

• Frailty
• Porcelain aorta or hostile chest
• Severe lung disease, liver disease, or malignancy
• Anatomic factors increasing surgical risk not captured by risk scores

Intermediate Surgical Risk (STS-PROM 3-10%)

Both TAVR and SAVR are appropriate options - the Heart Team should determine the optimal approach based on anatomic suitability, patient preference, and lifetime management considerations. 2, 3

Low Surgical Risk (STS-PROM <3%)

Both TAVR and SAVR are appropriate, with SAVR traditionally preferred in younger patients due to durability considerations, though recent data support TAVR in this population as well. 2, 3

Special Clinical Scenarios

Low-Flow, Low-Gradient AS with Reduced LVEF

Perform low-dose dobutamine stress echocardiography to differentiate true severe from pseudo-severe AS: 2

• With flow reserve and truly severe AS: AVR is "Appropriate" (score 8-9) regardless of surgical risk 1
• Without flow reserve but heavy calcification or projected severe AVA: AVR is "Appropriate" (score 7), medical management "May Be Appropriate" (score 4) 1
• Minimal calcification suggesting pseudo-severe AS: Medical management is "Appropriate" (score 7), AVR "Rarely Appropriate" (score 2-3) 1
• Profoundly reduced LVEF (<20%): Medical management "May Be Appropriate" (score 4), AVR "Appropriate" (score 7) with careful patient selection 1

Concomitant Coronary Artery Disease

SAVR plus CABG is appropriate for all scenarios. 1 Catheter-based approaches (TAVR + PCI) are appropriate or may be appropriate for patients with intermediate/high surgical risk and less complex coronary disease (lower SYNTAX scores). 1

Patients Requiring Major Noncardiac Surgery

• Symptomatic patients or elective noncardiac surgery: AVR (TAVR or SAVR) is appropriate before the noncardiac procedure 1
• Asymptomatic, well-compensated patients with urgent noncardiac surgery: AVR, balloon valvuloplasty, or no intervention may all be appropriate 1

Failed Bioprosthetic Valves

Balloon valvuloplasty is rarely appropriate. 1 Choose between TAVR (valve-in-valve) or redo SAVR based on: 1

• Surgical risk assessment
• Size of existing prosthesis (SAVR preferred for ≤19 mm prostheses in low/intermediate risk due to higher residual gradients with valve-in-valve TAVR)
• Coronary anatomy and access

Critical Pitfalls to Avoid

1. Delaying intervention in symptomatic patients - Without intervention, mortality approximates 2% per month, with 50% mortality within 2 years of symptom onset 4, 2

2. Missing reduced LVEF - Even asymptomatic patients with LVEF <50% require prompt AVR 1, 2

3. Ignoring very severe AS - Patients with Vmax ≥5 m/sec or mean gradient ≥60 mmHg are at increased risk for death and should undergo AVR even if asymptomatic, especially with low surgical risk 1, 2

4. Bypassing the Heart Team - The decision between TAVR and SAVR must involve a multidisciplinary team including cardiologists, cardiac surgeons, and imaging specialists to optimize treatment selection 2, 3

5. Relying solely on risk scores - Frailty, porcelain aorta, and other factors not captured by STS-PROM significantly impact surgical risk and should guide TAVR selection 1