What is the management and treatment for aortic stenosis?

Management and Treatment of Aortic Stenosis

All symptomatic patients with severe aortic stenosis require aortic valve replacement (AVR), as this is the only treatment proven to improve survival and relieve symptoms. 1, 2

Initial Diagnostic Evaluation

• Transthoracic echocardiography is the primary diagnostic tool to assess valve area, peak velocity, mean gradient, and left ventricular ejection fraction (LVEF). 1, 2
• Coronary angiography is mandatory in all patients being evaluated for valve replacement to identify concomitant coronary artery disease requiring revascularization. 1, 3
• Exercise stress testing is crucial when symptom status is unclear, particularly in elderly patients with comorbidities or mobility limitations—exercise-induced symptoms or abnormal hemodynamic response indicates need for intervention. 4, 3

Heart Team Evaluation

• All patients must be evaluated by a multidisciplinary Heart Team (Class I recommendation) to determine optimal treatment strategy based on surgical risk, anatomic factors, comorbidities, and patient preferences. 4, 2

Treatment Algorithm for Symptomatic Severe AS

Choice Between TAVR vs. SAVR

The decision between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) is primarily based on surgical risk assessment and specific patient factors:

• Low surgical risk patients (<65 years old): SAVR is generally preferred, particularly for long life expectancy and absence of surgical contraindications. 1, 2
• Intermediate to high surgical risk patients: TAVR is an appropriate alternative to SAVR. 1
• High/extreme surgical risk patients: TAVR is preferred over SAVR, especially with porcelain aorta, hostile chest anatomy, frailty, multiple comorbidities, or oxygen-dependent lung disease. 2
• Prohibitive surgical risk: TAVR is the recommended approach. 1
• Significant coronary disease requiring CABG: This favors SAVR over TAVR in appropriate surgical candidates. 3

Valve Selection by Age

• European guidelines recommend surgical bioprosthesis for patients ≥65 years, while American guidelines use multiple age categories allowing for patient factors and preferences. 4
• Mechanical valve use is decreasing across all age groups. 4

Management of Asymptomatic Severe AS

Intervention is indicated in asymptomatic patients with severe AS under specific circumstances:

• LVEF <50% (ACC/AHA) or <55% (ESC/EACTS) without other explanation. 4, 1
• Abnormal exercise stress test showing exercise-induced symptoms or inadequate hemodynamic response. 1
• Very severe AS with peak velocity ≥5 m/s or mean gradient ≥60 mmHg. 1
• Undergoing cardiac surgery for another indication. 1
• Rapid disease progression (rapid change in peak jet velocity, disproportionate LV hypertrophy, severe valve calcification). 4

Key divergence: European guidelines recommend intervention at LVEF 55%, while American guidelines use 60% threshold over serial imaging. 4

Special Clinical Scenarios

Low-Flow, Low-Gradient AS with Reduced EF (LVEF 20-49%)

• Perform dobutamine stress echocardiography to confirm true severe AS and demonstrate flow reserve. 1, 2
• AVR is appropriate if flow reserve is present and truly severe AS is confirmed. 1
• Medical management is appropriate if pseudosevere AS is identified. 1

Critically Ill Patients with Cardiogenic Shock

• Balloon aortic valvuloplasty (BAV) is recommended as a bridge to definitive treatment (TAVR or SAVR) in hemodynamically unstable patients. 2
• After stabilization with BAV, patients should undergo Heart Team evaluation for definitive treatment. 2

Moderate AS

• Current guidelines do not recommend AVR for moderate AS at rest or on dobutamine stress, even with LV systolic dysfunction. 4
• However, there is excess mortality associated with moderate AS (mean gradient ≥20 mmHg, peak velocity ≥3 m/s), and ongoing trials are evaluating early TAVR in moderate AS with heart failure. 4

Medical Management

There is no specific medical therapy to prevent or halt leaflet calcification and disease progression. 5, 6

• Lipid-lowering therapy, antihypertensive drugs, and anticalcific therapy have not shown benefit in preventing AS progression in clinical trials. 6
• Standard cardiac risk factor modification and treatment of hypertension and comorbid conditions remain important. 5
• Medical management alone is rarely appropriate for symptomatic severe AS, regardless of surgical risk. 1, 2

Palliative Care

• For patients with life expectancy <1 year or moderate-to-severe dementia, palliative medical management with balloon valvuloplasty may be considered. 1, 2

Monitoring and Surveillance

• Asymptomatic patients require periodic echocardiographic and clinical monitoring as progression to symptoms is inevitable. 5
• Patient education about symptom recognition is critical, as symptom development mandates urgent evaluation. 5

Critical Pitfalls to Avoid

• Do not delay intervention in symptomatic patients—this significantly increases mortality risk, with approximately 50% mortality at 2 years without AVR. 5
• Do not attribute all chest pain to AS alone—systematic evaluation for coronary artery disease is mandatory as both conditions frequently coexist. 3
• Do not rely solely on transvalvular gradients in low-flow states—valve area calculation is essential for accurate diagnosis. 2
• Avoid vasodilators and ensure adequate preload during any invasive procedures to maintain hemodynamic stability. 3
• Do not perform elective non-cardiac surgery in symptomatic AS patients without first addressing the valve disease—consider AVR before surgery involving large volume shifts. 1