What is the recommended treatment for aortic stenosis and aortic regurgitation?

Treatment of Aortic Stenosis and Aortic Regurgitation

Aortic Stenosis Treatment

All symptomatic patients with severe aortic stenosis require aortic valve replacement (AVR), either surgical (SAVR) or transcatheter (TAVR), as this is the only definitive treatment that improves survival and quality of life. 1

Symptomatic Severe AS

• Immediate AVR is indicated for any patient presenting with classic symptoms: heart failure, angina, or syncope 2, 3
• Survival decreases rapidly once symptoms appear, making prompt intervention critical 3
• Choice between SAVR vs TAVR depends on surgical risk stratification:
  • Low risk (STS-PROM <3%): SAVR is standard of care 1
  • Intermediate risk (STS-PROM 3-10%): Either SAVR or TAVR is appropriate 1
  • High/prohibitive risk: TAVR is preferred 1

Asymptomatic Severe AS

The decision to intervene depends on specific high-risk features 1:

AVR is appropriate when any of the following are present:

• LVEF <50% without other explanation 1
• Peak velocity ≥5.0 m/s 1
• Rapid progression (ΔVmax >0.3 m/s/year) 1
• Severe valve calcification 1
• Elevated BNP 1
• Excessive LV hypertrophy without hypertension 1
• Abnormal exercise test (symptoms, hypotension, or complex arrhythmias) 1
• High-risk profession (airline pilot) or competitive athlete 1

Watchful waiting is appropriate for asymptomatic patients with Vmax 4.0-4.9 m/s, negative exercise test, preserved LVEF ≥50%, and no high-risk features 1, 3

AS with Severe LV Dysfunction

• AVR is indicated even with LVEF <30% if no other cause for dysfunction is identified 4
• Despite increased operative risk, AVR improves functional status and EF in most patients 4
• Dobutamine stress echo helps exclude pseudo-severe AS (low-flow, low-gradient with flow reserve) 1

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Aortic Regurgitation Treatment

All symptomatic patients with severe aortic regurgitation require surgical AVR regardless of LV systolic function, as this is the only treatment that prevents irreversible LV damage and improves survival. 1

Symptomatic Severe AR

• Surgery is indicated immediately for any symptoms (dyspnea, heart failure, angina) regardless of LVEF 1
• Mortality reaches 19% within 6.6 years even in asymptomatic severe AR, and 75% die or require surgery within 10 years of diagnosis 1

Asymptomatic Severe AR

Surgery is indicated when any of the following thresholds are met:

LV systolic dysfunction:

• LVEF ≤50% (ESC/JCS) or ≤55% (ACC/AHA) without other cause 1

LV dilatation (even with preserved LVEF):

• LVESD >50 mm or >25 mm/m² (ESC) 1
• LVESD >45 mm (ACC/AHA) 1
• LVEDD >65 mm (ACC/AHA) or >60 mm (ESC) 1
• LVESDI ≥20 mm/m² 1

Progressive LV changes:

• Progressive decline in LVEF on ≥3 serial studies 1
• Progressive LV dilatation into severe range 1

Acute Severe AR

• Urgent surgery is required after brief medical stabilization with afterload reduction (vasodilators) 1
• Medical therapy should not delay surgical intervention 1

Surgical Approach

• Mechanical or bioprosthetic AVR is standard 1
• Aortic valve repair may be considered at experienced centers with favorable anatomy 1
• Aortic root replacement is reasonable when aortic diameter ≥45 mm in patients already undergoing AVR 1
• TAVI should not be performed in isolated severe AR patients who are surgical candidates 1
• TAVI may be considered only in highly selected patients ineligible for SAVR at experienced centers 1

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Mixed Valvular Disease

AS with Concomitant MR

Primary MR (will not improve with AS correction alone):

• Low/intermediate risk: Double valve surgery (AVR + mitral intervention) 1
• High risk: TAVR alone may be appropriate if AS is dominant lesion and mitral clip not feasible 1

Secondary MR (may improve with AS correction):

• Treat AS first; secondary MR often improves after isolated AVR/TAVR 1, 5
• Re-evaluate MR severity after aortic valve intervention 5

AR with Concomitant Valve Disease

• Severe AR + severe MR: Both valves should be addressed surgically 1
• Severe AR + moderate MR: Decision based on predominant lesion; if AR requires surgery, treating moderate MR is reasonable 1
• Careful assessment required to determine which valve pathology is dominant 1

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Monitoring and Follow-up

Asymptomatic Severe AS

Serial Doppler echocardiography 3:

• Every 6-12 months for severe AS
• Every 1-2 years for moderate AS
• Every 3-5 years for mild AS

Asymptomatic Severe AR

Serial echocardiography monitoring of LV dimensions and function 1:

• More frequent monitoring required with dilating LV
• CMR or CT useful for progressive LV function decline 1

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Critical Pitfalls to Avoid

• Do not delay surgery in symptomatic severe AS or AR – outcomes worsen rapidly once symptoms develop 1, 2, 3
• Do not assume asymptomatic status in elderly patients – perform exercise testing if symptom status unclear due to comorbidities or limited mobility 1, 3
• Do not withhold AVR in severe LV dysfunction (LVEF <30%) – most patients still benefit despite higher operative risk 4
• Do not perform TAVI for isolated severe AR in surgical candidates – outcomes are inferior to SAVR 1
• Do not assume all MR requires treatment at time of AS intervention – secondary MR often improves after isolated aortic valve treatment 1, 5