What is the management of severe aortic stenosis?

From the Guidelines

Management of severe aortic stenosis primarily involves surgical intervention with aortic valve replacement (AVR) as the definitive treatment, with transcatheter aortic valve replacement (TAVR) being a viable alternative for high-risk surgical candidates, as supported by the most recent evidence from 2024 1.

Key Considerations

• Patients with symptomatic severe aortic stenosis should be referred for AVR promptly, as untreated symptomatic disease carries a poor prognosis with mortality rates of approximately 50% at two years.
• For high-risk surgical candidates, TAVR offers an alternative approach, with studies demonstrating favorable outcomes using a wide spectrum of endpoints, including survival, symptom status, quality of life, and need for repeat hospitalizations 1.
• While awaiting intervention, medical therapy focuses on symptom management and includes diuretics for volume overload, cautious use of beta-blockers or non-dihydropyridine calcium channel blockers for rate control in atrial fibrillation, and avoidance of vasodilators which can precipitate hypotension.
• ACE inhibitors should be used cautiously and at low doses if needed for heart failure symptoms.
• Regular follow-up with echocardiography is essential, typically every 6-12 months for severe stenosis.
• Endocarditis prophylaxis is not routinely recommended except in specific high-risk situations.
• Balloon valvuloplasty may serve as a bridge to definitive treatment in critically ill patients but is not a long-term solution due to high restenosis rates.

Pathophysiology and Treatment Options

• The pathophysiology involves progressive valve calcification leading to left ventricular pressure overload, hypertrophy, and eventually heart failure if left untreated.
• Treatment options include surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR), with the choice of treatment depending on the patient's surgical risk and other factors, as outlined in the 2017 ACC expert consensus decision pathway for TAVR 1.
• The European Society of Cardiology quality indicators for the care and outcomes of adults undergoing TAVI provide further guidance on the management of severe symptomatic aortic stenosis, emphasizing the importance of a Heart Valve Team and consideration of several key factors, such as clinical site selection, operator and team training and experience, patient selection and evaluation, procedural performance and complication management, and postprocedural care 1.

From the Research

Severe Aortic Stenosis Management

• Severe aortic stenosis is a condition that affects 3% of persons older than 65 years, and its management is crucial to prevent rapid decrease in survival after symptoms appear 2.
• The management of severe aortic stenosis involves aortic valve replacement, which is recommended for most symptomatic patients with evidence of significant aortic stenosis on echocardiography 2.
• Watchful waiting is recommended for most asymptomatic patients, but select patients may also benefit from aortic valve replacement before the onset of symptoms 2.
• Surgical valve replacement is the standard of care for patients at low to moderate surgical risk, while transcatheter aortic valve replacement may be considered in patients at high or prohibitive surgical risk 2, 3.

Treatment Strategies

• The decision between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) requires thorough consideration by the heart team, incorporating patient preferences, clinical indicators, and anatomic aspects 3.
• TAVR has been approved for the treatment of severe aortic stenosis in intermediate- and low-risk patients as an alternative to SAVR, but the longer life expectancy of these groups of patients might exceed the durability of the TAVR or SAVR bioprosthetic valves 3.
• Percutaneous coronary intervention (PCI) should be considered for severely stenotic lesions in proximal coronaries that subtend a large area of myocardium at risk in patients with severe aortic stenosis and coronary artery disease (CAD) 4, 5.

Comparison of Treatment Outcomes

• Patients with severe aortic stenosis treated in heart valve centres (HVCs) have better outcomes compared to those treated in primary/secondary care centres, with higher rates of aortic valve replacement and improved one-year survival rates 6.
• The treatment of patients with severe aortic stenosis and CAD requires a multidisciplinary approach, with consideration of the underlying disease severity, antithrombotic treatment strategies, clinical presentation, and symptom evolution after TAVR 5.

Clinical Considerations

• Serial Doppler echocardiography is recommended every six to 12 months for severe aortic stenosis, every one to two years for moderate disease, and every three to five years for mild disease to monitor disease progression 2.
• Cardiology referral is recommended for all patients with symptomatic moderate and severe aortic stenosis, those with severe aortic stenosis without apparent symptoms, and those with left ventricular systolic dysfunction 2.
• Medical management of concurrent hypertension, atrial fibrillation, and coronary artery disease is crucial to achieve optimal outcomes in patients with severe aortic stenosis 2.