From the Guidelines
The next treatment option for this patient with severe aortic stenosis (AS) is surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR), depending on the patient's surgical risk profile. The echocardiographic findings clearly indicate severe AS with a peak velocity >4 m/s, mean gradient >40 mmHg, and valve area <1.0 cm2, meeting all three primary criteria for severe AS, as outlined in the 2017 appropriate use criteria for the treatment of patients with severe aortic stenosis 1. The normal stroke volume index (>35 ml/m2) confirms this is true severe AS rather than low-flow, low-gradient AS.
For a low surgical risk patient under 65-70 years, SAVR with a mechanical or biological valve would be preferred, as it provides a more durable solution with lower risk of valve failure, as noted in the 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement 1. For intermediate or high surgical risk patients, especially those over 75 years, TAVR would be the preferred option, as it has been shown to be a safe alternative to SAVR in patients in whom surgery is feasible but who are considered to be intermediate or high risk, as discussed in the 2017 appropriate use criteria for the treatment of patients with severe aortic stenosis 1.
While awaiting intervention, the patient should receive medical therapy including careful blood pressure management (targeting 130-140/70-90 mmHg), avoidance of vasodilators, and heart failure management if symptoms are present. Statins should be continued if already prescribed, but should not be initiated specifically for AS, as stated in the 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement 1. The patient should be advised to report promptly any symptoms of angina, syncope, or heart failure, as symptomatic severe AS carries a poor prognosis without intervention. Early heart team evaluation is essential to determine the optimal intervention strategy based on the patient's age, comorbidities, and anatomical considerations.
Some key considerations in the decision-making process include:
- The patient's surgical risk profile, which will influence the choice between SAVR and TAVR
- The presence of comorbidities, such as coronary artery disease or other valve disease, which may impact the choice of intervention
- The patient's age and functional status, which will influence the decision to proceed with intervention and the choice of valve type
- The need for careful blood pressure management and avoidance of vasodilators to minimize the risk of complications while awaiting intervention.
From the Research
Treatment Options for Severe Aortic Valve Stenosis
Given the patient's condition with a peak velocity of 418 cm/s, mean gradient of 42 mmHg, aortic valve area of 0.9 cm2, and an LVOT Stroke Volume Index of 40.2 ml/m2, the following treatment options are considered:
- Transcatheter Aortic Valve Replacement (TAVR): TAVR has become a preferred treatment option for patients with symptomatic severe aortic stenosis 2. It is a minimally invasive procedure that has shown promising results in patients with severe aortic stenosis, including those with bicuspid aortic valve, small aortic annuli, and low-flow, low-gradient AS 2.
- Surgical Aortic Valve Replacement (SAVR): SAVR is the most effective therapy for aortic stenosis, but its indication is sometimes difficult, and it may be impossible for high operative risk patients 3. However, SAVR is still a viable option for patients with severe aortic stenosis, especially those with low operative risk 4.
- Comparison of TAVR and SAVR: Studies have compared the effectiveness and safety of TAVR and SAVR in patients with severe aortic stenosis. While TAVR may reduce the risk of certain side effects, such as major bleeding and acute kidney injury, SAVR may reduce the risk of others, such as major vascular complications and permanent pacemaker implantation 5.
Key Considerations
When selecting a treatment option, the following factors should be considered:
- Patient risk profile: Patients with high operative risk may be more suitable for TAVR, while those with low operative risk may be more suitable for SAVR 3, 5.
- Valve type: The choice of valve type, such as self-expanding or balloon-expandable, may affect outcomes, with self-expanding valves associated with higher rates of moderate-to-severe paravalvular aortic regurgitation and permanent pacemaker placement 6.
- Individual patient characteristics: Patient preferences, comorbidities, and other individual characteristics should be taken into account when making a treatment decision 5.