Aortic stenosis general approach

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]; Sabawoon Mirwais, M.B.B.S, M.D.[3]; Rim Halaby; Usama Talib, BSc, MD [4]

Overview

Once a patient with aortic stenosis becomes symptomatic, aortic valve replacement should be performed as long as the patient can tolerate surgery and has no co-morbidities. If severe left ventricular dysfunction is present in the setting of aortic stenosis, it is of utmost importance to differentiate between true severe aortic stenosis and pseudo-severe aortic stenosis as these two entities have different pathophysiologies and different outcomes after aortic valve replacement.[1] Medical therapy reduces symptoms but does not prolong life. If a patient has extensive co-morbidities, transcatheter aortic valve implantation can be considered. Aortic valvuloplasty can be considered in those patients who are too sick for surgery or transcatheter aortic valve implantation.[2]

General Approach

The general approach to treating Aortic Valve Stenosis has the following important aspects.[3]

Shown below is an algorithm summarizing the management of symptomatic and asymptomatic patients with aortic stenosis and the indications for AVR. If the patient does not meet any of the decision pathways in the algorithm, regular monitoring is recommended and AVR is not indicated.[5][6]

Abbreviations: AVR: Aortic valve replacement; LVEF: Left ventricular ejection fraction; ΔPmean: mean pressure gradient; Vmax: maximum velocity

 
 
 
 
 
 
 
 
 
 
 
Abnormal aortic valve
AND
Reduction in systolic opening
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe aortic stenosis:
Vmax≥4m/s
AND
ΔPmean≥40 mmHg
 
 
 
 
 
 
 
 
 
 
Vmax3-3.9 m/s
AND
ΔPmean20-39 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
(Stage D1)
 
 
 
 
 
No
(Stage C)
 
 
 
Yes
 
 
 
No
(Stage B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LVEF <50%
(Stage C2)
 
 
 
 
Is LVEF <50%?
 
 
 
The patient is undergoing
another cardiac surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient is undergoing
another cardiac surgery
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vmax≥5m/s
AND
ΔPmean≥60 mmHg
(Very severe stage C1)
AND
Low surgical risk
 
 
Dobutamine stress echocardiography:
Aortic valve area ≤1 cm2
AND
Vmax≥4 ms
(Stage D2)
 
Aortic valve area ≤1 cm2
AND
LVEF ≥50%
(Stage D3)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal exercise treadmill test
 
 
 
 
 
 
 
The symptoms are likely
the result of the aortic stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ΔVmax>0.3 m/s/y
AND
Low surgical risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AVR (Class I)
 
AVR (Class IIa)
 
AVR (Class IIb)
 
AVR (Class IIa)
 
AVR (Class IIa)
 
AVR (Class IIa)

Shown below is an algorithm summarizing the approach to patients with low flow, low gradient aortic stenosis.[1]

Abbreviations: AVR: Aortic valve replacement; EOA: Effective orifice area; ΔPmean: mean pressure gradient

 
 
Ultrasound evaluation of aortic stenosis
Effective orifice area (EOA)≤ 1 cm2
Pressure gradient (ΔP)<40 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low grade low flow aortic stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal left ventricular ejection fraction
 
Left ventricular ejection fraction≤ 40-50%[6]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No specific recommendations:
- Surgical AVR, or
- Transcather AVR, or
- Medical treatment
 
 
 
 
 
 
 
 
 
 
 
Dobutamine stress test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increase in stroke volume by ≥ 20%
 
Increase in stroke volume by <20%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of left ventricular flow reserve
 
Absence of left ventricular flow reserve
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ΔP≥40
EOA<1-1.2
 
ΔP<40
EOA≥1-1.2
 
EOA<1-1.2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
True severe aortic stenosis
 
Pseudo-severe aortic stenosis
 
True severe aortic stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical AVR
with/without CABG
 
Medical treatment
Close follow up
 
Transcather AVR


Available Therapeutic Options

Following are some of the available therapeutic options for Aortic Stenosis.[3][7]

ESC/EACTS Guidelines

Indications for Intervention in Aortic Stenosis and Recommendations for the Choice of Intervention Mode[8]


Symptomatic Aortic Stenosis Class of Recommendation Level of Evidence
Intervention is indicated in symptomatic patients with severe, high-gradient aortic stenosis (mean gradient ≥ 40 mmHg or peak velocity ≥ 4.0 m/s)[9][10][11] I B
Intervention is indicated in symptomatic patients with severe low-flow, low-gradient (< 40 mmHg) aortic stenosis with reduced ejection fraction and evidence of flow (contractile) reserve excluding pseudosevere aortic stenosis I C
Intervention should be considered in symptomatic patients with low-flow, low-gradient (< 40 mmHg) aortic stenosis with normal ejection fraction after careful confirmation of severe aortic stenosisa IIa C
Intervention should be considered in symptomatic patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction without flow (contractile) reserve, particularly when CT calcium scoring confirms severe aortic stenosis IIa C
Intervention should not be performed in patients with severe comorbidities when the intervention is unlikely to improve quality of life or survival III C
Choice of Intervention in Symptomatic Aortic Stenosis
Aortic valve interventions should only be performed in centres with both departments of cardiology and cardiac surgery on site and with structured collaboration between the two, including a Heart Team (heart valve centres) I C
The choice for intervention must be based on careful individual evaluation of technical suitability and weighing of risks and benefits of each modality. In addition, the local expertise and outcomes data for the given intervention must be taken into account I C
SAVR is recommended in patients at low surgical risk (STS or EuroSCORE II < 4% or logistic EuroSCORE I < 10%b and no other risk factors not included in these scores, such as frailty, porcelain aorta, sequelae of chest radiation)[11] I B
TAVR is recommended in patients who are not suitable for SAVR as assessed by the Heart Team[9][12] I B
In patients who are at increased surgical risk (STS or EuroSCORE II ≥ 4% or logistic EuroSCORE I ≥ 10%b or other risk factors not included in these scores such as frailty, porcelain aorta, sequelae of chest radiation), the decision between SAVR and TAVR should be made by the Heart Team according to the individual patient characteristics, with TAVR being favored in elderly patients suitable for transfemoral access[9][12][13][14][15][16][17][18][19][20] I B
Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVR in hemodynamically unstable patients or in patients with symptomatic severe aortic stenosis who require urgent major non-cardiac surgery IIb C
Balloon aortic valvotomy may be considered as a diagnostic means in patients with severe aortic stenosis or other potential causes for symptoms (i.e. lung disease) and in patients with severe myocardial dysfunction, pre-renal insufficiency, or other organ dysfunction that may be reversible with balloon aortic valvotomy when performed in centers that can escalate to TAVR IIb C
Asymptomatic Patients With Severe Aortic Stenosis (Refers Only to Patients Eligible for Surgical Valve Replacement)
SAVR is indicated in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) not due to another cause I C
SAVR is indicated in asymptomatic patients with severe aortic stenosis and an abnormal exercise test showing symptoms on exercise clearly related to aortic stenosis I C
SAVR should be considered in asymptomatic patients with severe aortic stenosis and an abnormal exercise test showing a decrease in blood pressure below baseline IIa C
SAVR should be considered in asymptomatic patients with normal ejection fraction and none of the above-mentioned exercise test abnormalities if the surgical risk is low and one of the following findings is present:
  • Very severe aortic stenosis defined by a Vmax > 5.5 m/s
  • Severe valve calcification and a rate of Vmax progression ≥ 0.3 m/s/year
  • Markedly elevated BNP levels (> threefold age- and sex-corrected normal range) confirmed by repeated measurements without other explanations
  • Severe pulmonary hypertension (systolic pulmonary artery pressure at rest > 60 mmHg confirmed by invasive measurement) without other explanation
IIa C
Concomitant Aortic Valve Surgery at the Time of Other Cardiac/Ascending Aorta Surgery
SAVR is indicated in patients with severe aortic stenosis undergoing CABG or surgery of the ascending aorta or of another valve I C
SAVR should be considered in patients with moderate aortic stenosisc undergoing CABG or surgery of the ascending aorta or of another valve after Heart Team decision IIa C
BNP = B-type natriuretic peptide; CABG = coronary artery bypass grafting; CT = computed tomography; EuroSCORE = European System for Cardiac Operative Risk Evaluation; LV = left ventricular; LVEF = left ventricular ejection fraction; SAVR = surgical aortic valve replacement; STS = Society of Thoracic Surgeons; TAVR = transcatheter aortic valve replacement; Vmax = peak transvalvular velocity
  • aIn patients with a small valve area but low gradient despite preserved LVEF, explanations for this finding other than the presence of severe aortic stenosis are frequent and must be carefully excluded.
  • bSTS score (calculator: http://riskcalc.sts.org/stswebriskcalc/#/calculate); EuroSCORE II (calculator: http://www.euroscore.org/calc.html); logistic EuroSCORE I (calculator:http://www.euroscore.org/calcge.html); scores have major limitations for practical use in this setting by insufficiently considering disease severity and not including major risk factors such as frailty, porcelain aorta, chest radiation, etc. EuroSCORE I markedly overestimates 30-day mortality and should therefore be replaced by the better-performing EuroSCORE II with this regard; it is nevertheless provided here for comparison, as it has been used in many TAVR studies/registries and may still be useful to identify the subgroups of patients for decision between intervention modalities and to predict 1-year mortality.
  • cModerate aortic stenosis is defined as a valve area of 1.0–1.5 cm2 or a mean aortic gradient of 25–40 mmHg in the presence of normal flow conditions. However, clinical judgement is required.

References

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