What is the recommended treatment for a patient with severe symptomatic aortic stenosis?

Treatment for Severe Symptomatic Aortic Stenosis

Aortic valve replacement (AVR) is the definitive treatment for all patients with severe symptomatic aortic stenosis, regardless of surgical risk, and medical management alone is associated with dramatically worse survival. 1, 2

Primary Treatment Recommendation

• AVR is rated "Appropriate" (score 8-9) for all symptomatic patients with severe aortic stenosis, while medical management alone is rated "Rarely Appropriate" (score 1-3). 1, 2
• Observational data demonstrate that survival at 1,2, and 5 years in unoperated symptomatic patients is only 67%, 56%, and 38%, respectively, compared with 94%, 93%, and 90% in those who underwent AVR. 3
• Delaying intervention in symptomatic patients leads to increased mortality, and prompt referral for AVR is essential. 1

Selecting Between TAVR and SAVR Based on Surgical Risk

The choice between transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) depends on a Heart Team assessment of surgical risk: 1, 2

High Surgical Risk Patients

• TAVR is the preferred procedure for patients with high or extreme surgical risk (STS-PROM ≥8% or 30-day mortality risk ≥15%). 1, 2
• TAVR demonstrated superiority over medical therapy in inoperable patients, with sustained mortality benefit at 2 years (43.3% vs 68.0% mortality, P<0.001). 4

Intermediate Surgical Risk Patients

• Both TAVR and SAVR are appropriate options for intermediate-risk patients (STS-PROM 3-10%), with the choice depending on individual risk profile and anatomic suitability. 1, 2
• The decision should involve evaluation of patient anatomy, frailty, comorbidities, and patient preference by the Heart Team. 2

Low Surgical Risk Patients

• SAVR is preferred for low surgical risk patients, though TAVR is a reasonable alternative in selected patients after Heart Team evaluation. 2
• Recent trials have shown encouraging results for TAVR in low-risk patients, making it an increasingly viable option. 5, 6

Special Clinical Scenarios Requiring Intervention

Reduced Left Ventricular Ejection Fraction

• AVR is indicated for asymptomatic patients with LVEF <50% without another cause, regardless of surgical risk (Class I recommendation). 2, 7
• Even asymptomatic patients with reduced LVEF due to AS require AVR, as this represents a high-risk feature predicting adverse outcomes. 2

Very Severe Aortic Stenosis

• AVR is appropriate for patients with very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg), even if asymptomatic, when operative mortality is low (<1%). 2, 7
• These patients are at increased risk for death and indication-driven AVR. 8

Low-Flow, Low-Gradient Aortic Stenosis

• Dobutamine stress echocardiography should be performed to distinguish true-severe from pseudo-severe AS in patients with low-flow, low-gradient AS and reduced LVEF. 1, 2
• AVR is indicated if flow reserve is present and truly severe AS is confirmed. 1, 2

Concurrent Cardiac Surgery

• AVR is appropriate (and failure to intervene is rarely appropriate) when the patient with severe AS undergoes cardiac surgery for another indication or ascending aortic surgery. 8

Anatomical Considerations Favoring TAVR

• TAVR is recommended for patients with porcelain aorta or hostile chest anatomy. 2
• TAVR is also recommended for patients with prior cardiac surgery with patent grafts at risk during reoperation. 2

Role of Medical Management

• There is no evidence supporting specific medical treatment to prevent AS progression or improve outcomes. 2, 7, 9
• Supportive medical management principles include maintaining adequate preload (avoiding aggressive diuresis), controlling heart rate to preserve diastolic filling time, and managing concurrent conditions optimally. 2, 7
• Beta blockers and statins may potentially improve survival in unoperated patients, though this does not substitute for AVR. 3

Critical Pitfalls to Avoid

• Do not delay intervention in symptomatic patients, as observational data demonstrate poor survival rates without AVR. 1, 2
• Do not overlook reduced LVEF, as even asymptomatic patients with LVEF <50% due to AS require AVR. 1, 2
• Do not fail to recognize very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg), as these patients are at higher risk for adverse outcomes. 1
• Do not make treatment decisions without involving a multidisciplinary Heart Team, as the decision between TAVR and SAVR should involve cardiologists, cardiac surgeons, imaging specialists, and other relevant specialists. 1, 2
• Be aware that TAVR has higher rates of moderate or severe paravalvular leak, conduction abnormalities requiring permanent pacemaker, and vascular complications compared to SAVR, though these complications have decreased with newer devices. 6