What is the best management approach for an elderly patient with severe aortic stenosis, reduced ejection fraction, and potential comorbidities?

Management of Severe Aortic Stenosis with Reduced Ejection Fraction

For a patient with severe aortic stenosis and reduced ejection fraction, aortic valve replacement is mandatory regardless of age or symptoms, with the choice between mechanical/surgical versus transcatheter replacement determined primarily by surgical risk assessment using the STS-PROM score. 1

Immediate Decision: Intervention is Required

• Reduced ejection fraction (<50%) in severe aortic stenosis is a Class I indication for aortic valve replacement regardless of symptoms or age. 1, 2
• Medical management alone is considered rarely appropriate (appropriateness score 1-2) and should not be pursued. 1
• The presence of reduced LVEF eliminates the need for stress testing—intervention is appropriate based on the reduced ejection fraction alone. 1

Critical First Step: Distinguish True-Severe from Pseudo-Severe AS

Before proceeding to valve replacement, you must perform dobutamine stress echocardiography to confirm truly severe stenosis versus pseudo-severe stenosis in the setting of low-flow, low-gradient physiology. 1, 2, 3

If flow reserve is present on dobutamine:

• AVA remains ≤1.0 cm² and Vmax >4 m/s = True severe AS → Proceed with AVR (appropriateness score 8-9) 1
• AVA increases to >1.0 cm² and Vmax <4 m/s = Pseudo-severe AS → Primary myocardial problem, surgery unlikely to prolong life 4, 3

If no flow reserve but valve is heavily calcified on echo/CT:

• This still suggests truly severe AS → AVR remains appropriate (appropriateness score 7) 1

Choosing Between TAVR vs. SAVR: The Algorithm

Step 1: Calculate STS-PROM Score

For STS-PROM <3% (Low Risk):

• Surgical AVR is strongly preferred over TAVR, particularly for patients in their 60s-70s (appropriateness score 9). 1
• Mechanical valve replacement should be considered in younger patients (<65 years) where long-term durability is critical. 1

For STS-PROM ≥8% (High Risk):

• TAVR is preferred over SAVR. 4, 1
• Both TAVR and SAVR are appropriate (appropriateness score 8) if intermediate risk. 1

For STS-PROM 3-8% (Intermediate Risk):

• Either SAVR or TAVR is appropriate; decision depends on additional factors below. 4, 1

Step 2: Assess Additional Risk Factors Favoring TAVR

Even with lower surgical risk scores, TAVR becomes preferred if any of these factors are present:

• Porcelain aorta or hostile chest anatomy 4, 1
• Frailty or severe disability 4, 1
• Prior cardiac surgery with mediastinal scarring 4
• Oxygen-dependent lung disease 4
• Dialysis dependence 4
• Cirrhosis with MELD >14 4
• Small aortic annulus requiring prosthesis <21 mm 4

Step 3: Assess Factors Favoring SAVR

SAVR remains preferred when:

• Age <65 years with longer life expectancy requiring valve durability 1
• Concomitant cardiac pathology requiring surgical correction (other valve disease, ascending aorta pathology, need for CABG) 4
• Aortic root anatomy unfavorable for TAVR (excessive calcification, annulus size out of range) 4
• Bicuspid aortic valve (relative contraindication to TAVR) 1

Special Considerations for Reduced Ejection Fraction

• LVEF <20% is a relative contraindication to TAVR and may favor SAVR if surgical risk is acceptable. 1
• Patients with severe AS and reduced EF show faster recovery of left ventricular function after TAVR compared to SAVR (EF improvement by day 7 vs. 3 months). 5
• Long-term prognosis is strongly correlated to EF recovery after intervention—only 50% of patients improve contractility after surgical AVR. 5, 6

Mandatory Requirements for TAVR

• Multidisciplinary Heart Team evaluation comprising cardiac surgery, interventional cardiology, cardiac imaging, anesthesiology, and geriatrics. 4, 1
• TAVR must be performed at hospitals with cardiac surgery on-site. 1
• Life expectancy must exceed 1 year for TAVR to be appropriate. 4, 1

Critical Pitfalls to Avoid

• Do not delay intervention waiting for symptoms to develop—reduced EF itself mandates intervention. 1, 2
• Do not skip dobutamine stress echo in low-flow, low-gradient scenarios—you risk operating on pseudo-severe AS where surgery won't help. 4, 1, 3
• Do not use loop diuretics excessively in patients with severe AS, LV hypertrophy, and small ventricular cavities—these are preload-dependent ventricles. 2
• Do not assume TAVR is always safer—for low-risk patients in their 60s, SAVR provides superior long-term durability. 1

Prognosis Without Intervention

• Asymptomatic severe AS with reduced EF: 67% 1-year survival without intervention. 7
• Once symptoms develop: 25% mortality at 1 year, 50% at 2 years without intervention. 7
• Operative mortality for low-flow, low-gradient AS with reduced EF is higher but still beneficial if truly severe stenosis. 3, 8