The management of severe aortic stenosis primarily involves aortic valve replacement (AVR), which can be performed surgically or via a transcatheter approach. The choice of intervention depends on the patient's clinical status, anatomical considerations, and procedural risk.
Indications for aortic valve replacement
- Symptomatic patients: AVR is recommended for symptomatic patients with severe high-gradient aortic stenosis (AS) (stage D1) and symptoms such as exertional dyspnea, heart failure, angina, syncope, or presyncope by history or on exercise testing
- Asymptomatic patients: AVR may be considered in asymptomatic patients with severe AS (defined as an aortic velocity of ≥ 5 m/s) and low surgical risk . It is also recommended for asymptomatic patients with severe AS (stage C1) undergoing cardiac surgery for other indications
- Low-flow, low-gradient severe AS: AVR is recommended for symptomatic patients with low-flow, low-gradient severe AS with reduced left ventricular ejection fraction (LVEF) (stage D2) and normal LVEF (stage D3) if AS is the most likely cause of symptoms
Choice of approach
- Surgical aortic valve replacement (SAVR): SAVR is recommended in patients with an indication for AVR if a bioprosthetic valve is preferred but valve or vascular anatomy or other factors are not suitable for transfemoral transcatheter aortic valve implantation (TAVI)
- Transcatheter aortic valve implantation (TAVI): TAVI is recommended in symptomatic patients of any age with severe AS and a high or prohibitive surgical risk if predicted post-TAVI survival is > 12 months with an acceptable quality of life (QoL)
Choice of valves
- Bioprosthetic valve: A bioprosthetic valve is recommended in patients of any age requiring AVR if vitamin K antagonists (VKAs) are contraindicated, cannot be managed appropriately, or not desired . It is also recommended in patients > 65 years of age requiring AVR
- Mechanical valve: A mechanical aortic prosthesis is recommended in patients < 50 years of age requiring AVR and not having a contraindication to anticoagulation
- Pulmonic autograft (Ross procedure): The Ross procedure is recommended at a comprehensive valve center in patients < 50 years of age with appropriate anatomy preferring bioprosthetic AVR
Specific circumstances
- Patients undergoing noncardiac surgery: AVR (SAVR or TAVI) is recommended in symptomatic patients with severe aortic valve stenosis scheduled for elective intermediate- or high-risk noncardiac surgery . It may also be considered in asymptomatic patients with severe aortic valve stenosis scheduled for elective high-risk noncardiac surgery after heart team discussion
In conclusion, the management of severe aortic stenosis requires a comprehensive evaluation of the patient's clinical status, anatomical considerations, and procedural risk to determine the most appropriate intervention. The choice of valve and approach should be individualized, taking into account the patient's age, comorbidities, and preferences.