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

Management of Severe Aortic Stenosis with Reduced Ejection Fraction

For an elderly patient with severe aortic stenosis and reduced ejection fraction, aortic valve replacement is indicated regardless of symptoms, with the choice between transcatheter (TAVR) versus surgical (SAVR) replacement determined primarily by surgical risk assessment using the STS-PROM score. 1

Primary Decision: Intervention is Mandatory

• Valve replacement is a Class I recommendation for all patients with severe aortic stenosis and reduced ejection fraction (<50%), regardless of symptom status. 1
• 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 to inform decision-making—intervention is appropriate based on the reduced ejection fraction alone. 1
• Even patients with severely reduced ejection fraction (LVEF 20-49%) benefit from valve replacement, though operative mortality is higher. 2

Critical Pre-Intervention Assessment: Distinguish True-Severe from Pseudo-Severe AS

Before proceeding with valve replacement in patients with low-flow, low-gradient aortic stenosis (mean gradient <40 mmHg with reduced LVEF), you must perform dobutamine stress echocardiography to confirm truly severe stenosis. 1, 2

• If dobutamine increases stroke volume by ≥20% (flow reserve present) AND the gradient increases while valve area remains ≤1.0 cm², this confirms truly severe AS and AVR is appropriate (appropriateness score 8-9). 1, 2
• If flow reserve is absent but the valve shows severe calcification on echocardiography or CT, this still suggests truly severe AS and AVR remains appropriate (appropriateness score 7). 1, 2
• If stroke volume increases but gradient does not increase significantly, this indicates pseudo-severe AS (primary myocardial problem), and surgery is unlikely to prolong life. 2, 3
• Patients with contractile reserve on dobutamine have better surgical outcomes than those without, but even some patients without reserve may benefit if valve calcification confirms severe stenosis. 2, 3

Choosing Between TAVR vs. SAVR: Risk-Based Algorithm

Calculate STS-PROM Score First

The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score is the primary determinant of approach. 1

For Low Surgical Risk (STS-PROM <4%):

• SAVR is strongly preferred over TAVR (appropriateness score 9), particularly for patients in their 60s. 1
• Mechanical valve replacement should be considered in younger patients (<65 years) who require long-term durability and can tolerate anticoagulation. 1
• SAVR provides superior valve durability and avoids issues with future valve-in-valve procedures. 1

For Intermediate Risk (STS-PROM 4-8%):

• Both TAVR and SAVR are appropriate options (appropriateness score 8). 1
• For patients aged 65-75 years, SAVR is generally preferred, though both are acceptable depending on comorbidities. 1

For High Risk (STS-PROM >8%):

• TAVR is preferred over SAVR. 1
• TAVR should only be performed at hospitals with cardiac surgery on-site. 1

Additional Factors Favoring TAVR Despite Lower Risk Scores

• Frailty (moderate to severe) 2, 1
• Porcelain aorta 1
• Hostile chest from prior cardiac surgery 1
• Significant comorbidities affecting surgical candidacy 1
• Multiple major organ system compromises (≥2) not expected to improve postoperatively 2

Contraindications and Futility Considerations

TAVR should not be performed if life expectancy from non-cardiac causes is <1 year, as benefit does not exceed risk. 2, 1

• Relative contraindications for TAVR include LVEF <20%, bicuspid valve, and untreated coronary artery disease requiring revascularization. 1
• If chance of survival with benefit at 2 years is <25%, intervention represents futility and palliative care should be discussed. 2

Mandatory Heart Team Evaluation

All decisions regarding valve replacement must involve a multidisciplinary Heart Valve Team assessment including cardiac surgery, interventional cardiology, imaging specialists, anesthesiology, and geriatrics. 2, 1

• The Heart Team should review medical condition, valve severity, technical feasibility, and discuss benefits/risks with patient and family. 2
• Shared decision-making must incorporate patient goals, life expectancy expectations, and anticipated symptom improvement. 2

Common Pitfalls to Avoid

• Do not deny intervention based solely on reduced ejection fraction—many patients with LVEF as low as 0.34 show dramatic improvement to 0.63 post-operatively. 4
• Do not proceed with valve replacement in low-flow, low-gradient AS without dobutamine testing—you may be replacing a non-severe valve in a patient with primary cardiomyopathy. 2, 3
• Do not choose TAVR in younger patients (<65 years) with low surgical risk—they need the durability of SAVR or mechanical valves. 1
• Do not perform TAVR at centers without on-site cardiac surgery. 1

Expected Outcomes

• Patients with severe AS and reduced EF who undergo valve replacement have significantly improved survival: 92% at 1 year, 85% at 3 years, and 73% at 5 years, compared to 65%, 29%, and 16% respectively with medical management. 5
• Valve replacement is independently associated with decreased mortality (hazard ratio 0.17). 5
• Most patients improve from NYHA Class III-IV to Class I-II post-operatively. 4