Approach Considerations
The only definitive treatment for aortic stenosis in adults is aortic valve replacement, performed surgically or percutaneously. The development of symptoms due to aortic stenosis provides a clear indication for replacement. For patients who are not candidates for aortic replacement, percutaneous aortic balloon valvuloplasty may provide some symptom relief. [4, 5] Infants, children and adolescents with a bicuspid valve may undergo balloon or surgical valvotomy.
The Leadership Council of the American College of Cardiology (ACC) recommends considering percutaneous coronary intervention (PCI) in all patients with significant proximal coronary stenosis in major coronary arteries before transcatheter aortic valve replacement (TAVR), even though the indication is not covered in current guidelines. [27]
Medical treatment (such as diuretic therapy) in aortic stenosis may provide temporary symptom relief but is generally not effective long term.
In truly asymptomatic patients with severe aortic stenosis, the issue of valve replacement is less clear. [5]
Consultation with a cardiologist or cardiothoracic surgeon is appropriate.
Emergency Department Care
Prehospital and emergency department management is focused on acute exacerbations of the symptoms of aortic stenosis. As always, assess and address airway, breathing, and circulation. If the patient is in cardiopulmonary arrest, perform resuscitation according to the recommendations of the AHA in their Advanced Cardiac Life Support guidelines. In patients with acute symptoms, hospital admission, telemetry/intensive care unit admission, and cardiology consultation all should be considered.
A patient presenting with uncontrolled heart failure should be treated supportively with oxygen, cardiac and oximetry monitoring, intravenous access, loop diuretics, nitrates (remembering the potential nitrate sensitivity of patients with aortic stenosis), morphine (as needed and tolerated), and noninvasive or invasive ventilatory support (as indicated). Patients with severe heart failure due to aortic stenosis that is resistant to medical management should be considered for urgent surgery.
A patient presenting with angina pectoris requires monitoring and studies as listed above. Measures should be taken to relieve the chest discomfort. This may include the administration of nitrates, oxygen, and morphine. However, nitroglycerin-induced syncope occurs more often in patients with aortic stenosis than in those without aortic stenosis. This information should be obtained through the history at presentation.
Syncope in the face of aortic stenosis should be assessed and treated as in any patient presenting with a syncopal episode.
Atrial fibrillation in the setting of aortic stenosis is considered a medical emergency, and sinus rhythm should be restored urgently in patients who are hemodynamically unstable. Associated symptoms also should be treated urgently.
Percutaneous Balloon Valvuloplasty
Percutaneous balloon valvuloplasty is used as a palliative measure in critically ill adult patients who are not surgical candidates or as a bridge to aortic valve replacement in critically ill patients. The high rate of restenosis and the absence of a mortality benefit preclude its use as a definitive treatment method in adults with severe aortic stenosis.
Valvuloplasty can be considered in cases of severe heart failure or cardiogenic shock for the following patients:
-
Patients with other comorbid conditions with a very short life expectancy
-
Patients who refuse surgery
-
Patients with heart failure who need an urgent, major noncardiac surgical procedure
-
Pregnant patients with critical aortic stenosis
In critically ill patients, the mortality rate associated with the procedure is 3-7%. Another 6% develop serious complications, including perforation, myocardial infarction, and severe aortic regurgitation.
In children, adolescents, and young adults with congenital aortic stenosis, percutaneous balloon valvuloplasty carries a mortality risk of 1% and may be an alternative to surgical valvotomy. The risk of causing significant aortic regurgitation is 10%. Although exercise restriction is sometimes recommended to avoid the risk of sudden unexpected death for some patients with congenital aortic stenosis, a recent study by Brown et al suggests that sudden unexpected death is extremely rare following balloon valvuloplasty, and the study found no beneficial effect for exercise restriction after the procedure is performed. [28]
The best results from valvuloplasty are obtained in the patients with a commissural bicuspid aortic valve, in whom a 60-70% reduction in gradient and a 60% increase in the AVA can be expected.
Restenosis is common, particularly in patients with unicuspid valves or with valves affected by severe dysplasia (>60% at 6 mo, virtually 100% at 2 y). However, repeat procedures have been shown to provide a median survival rate of approximately 3 years and to maintain clinical improvement. [29]
Aortic Valve Replacement
In most adults with symptomatic, severe aortic stenosis, aortic valve replacement is the surgical treatment of choice. If concomitant coronary disease is present, aortic valve replacement and coronary artery bypass graft (CABG) should be performed simultaneously. Successful aortic valve replacement produces substantial clinical and hemodynamic improvement in patients with aortic stenosis, including octogenarians.
Aortic valve replacement improves outcomes in patients with low-flow aortic stenosis. [13] Transcatheter aortic valve replacement (TAVR) may be a preferred therapy in this subset of aortic stenosis patients.
Bioprosthetic and mechanical valves
The choice of prosthesis is determined by the anticipated longevity of the patient and his/her ability to tolerate anticoagulation. [30]
Stassano et al found that bioprosthetic aortic valves were significantly less durable than were mechanical valves. In a prospective, randomized study of 310 patients aged 55-70 years, follow-up at 13 years showed that valve failures and reoperations were more frequent in the bioprosthesis group than in the mechanical prosthesis group. However, there were no differences between the two types of valves regarding the rates of survival, thromboembolism, bleeding, endocarditis, and major adverse prosthesis-related events. [31]
The surgical mortality risk in patients with normal LV systolic function and no other comorbid conditions is less than 5%. Risk factors for increased operative mortality include the following:
-
High New York Heart Association (NYHA) class (25-30% mortality in patients with class IV)
-
Preoperative LV systolic dysfunction
-
Older age
-
Associated aortic regurgitation
Overall, the 5-year survival rate in all adults after aortic valve replacement is 80-94%, and the 10-year survival rate is 68-89%. Risk factors for late death include the following:
-
High preoperative NYHA class
-
LV systolic dysfunction
-
Preoperative ventricular arrhythmias
-
Concomitant aortic regurgitation
-
Atrial fibrillation
-
Coronary artery disease, particularly a history of myocardial infarction
Ross procedure
The Ross procedure is another option in young patients as an initial procedure or for reoperation after prior valvotomy. In this procedure, the patient's own pulmonary valve and main pulmonary artery are transplanted to the aortic position, with reimplantation of coronary arteries. A homograft is placed in the pulmonary position. Its durability may be better than tissue valves. However, the Ross procedure is technically demanding and results at different centers have been mixed.
Percutaneous transcatheter valve replacement
Many patients with severe aortic stenosis and coexisting conditions are not candidates for, or are at high risk for complications with, surgical replacement of the aortic valve. Studies have suggested that percutaneous transcatheter aortic-valve replacement (TAVR) with a balloon-expandable bovine pericardial valve is a less invasive option for these high-risk patients. [5, 32, 33] In a study comparing TAVR (via a transfemoral or a transapical approach) and surgical replacement in patients who were candidates for valve replacement but considered to be high risk, survival at 1 year was similar for both procedures. [34] However, important differences in periprocedural risks were observed; major vascular complications and stroke were more frequent with TAVR, whereas major bleeding and new-onset atrial fibrillation were more frequent with surgical valve replacement.
A comprehensive literature review by Daneault evaluated the incidence of stroke after surgical and transcatheter treatment for aortic stenosis. The risk of stroke for the general population after aortic valve replacement was 1.5% (2-4% in higher risk and elderly patients). The rate after transcatheter treatment was 1.5-6%. This review shows a trend for more strokes in the transcatheter group. [35]
In the Placement of Aortic Transcatheter Valves (PARTNER) trial, inoperable patients with severe aortic stenosis had improved survival with TAVR compared with medical management. [36] In high-risk patients, survival was similar with TAVR and surgical aortic valve replacement. In all the patient cohorts, low flow (stroke volume index ≤35 mL/m2) was an independent predictor of mortality, whereas low ejection fraction and mean gradient were not. [36]
Also in the PARTNER trial, patients with critical aortic stenosis after either surgical aortic valve replacement (SAVR) or TAVR showed decreased aortic valve gradients and increased effective orifice area (EOA) on echocardiography through 2 years of follow-up. [37] Univariate postimplantation echocardiographic predictors of death in the TAVR group were as follows:
-
Larger left ventricular systolic and diastolic volumes
-
Larger EOA
-
Greater aortic regurgitation
-
Decreased ejection fraction
In the SAVR group, the predictors of death were as follows:
-
Smaller left ventricular systolic and diastolic volumes
-
Smaller EOA
-
Low stroke volume
-
Prosthesis-patient mismatch
Five-year outcomes from the PARTNER trial showed similar outcomes between high-risk patients with aortic stenosis who underwent TAVR and those who underwent surgical aortic valve replacement (SAVR). [38] At 5 years, risk of death was 67.8% in the TAVR group versus 62.4% in the SAVR group. Neither group reported structural valve deterioration requiring surgical valve replacement. However, moderate or severe aortic regurgitation occurred in 40 of 280 (14%) patients in the TAVR group but in only 2 of 228 (1%) patients in the SAVR group; this was associated with increased 5-year risk of mortality in the TAVR group. [38]
In another randomized study, TAVR using a self-expanding transcatheter aortic-valve bioprosthesis (CoreValve) was associated with a significantly higher survival rate at 1 year follow-up than surgical aortic-valve replacement. [39, 40] The study consisted of 795 patients with severe aortic stenosis who were at increased surgical risk. The rate of death from any cause at 1 year was 14.2% in the TAVR group and 19.1% in the surgical group (P = 0.04). The risk of stroke at 30 days was 4.9% with TAVR and 6.2% with surgery. [39, 40]
In June 2014, the FDA widened the indication for the self-expanding transcatheter aortic-valve bioprosthesis CoreValve to include patients with symptomatic severe aortic stenosis who are at high risk for surgery. [41, 42] The original indication approved in January 2014 was for patients considered at extreme risk and thus not surgical candidates. [41]
Approval for the expanded indication was based on data from the head-to-head High-Risk Study of the CoreValve US Pivotal Trial, in which patients who underwent TAVR with CoreValve had a significantly higher 1-year survival rate (85.8%) compared with those who underwent surgical valve replacement (80.9%). [41, 42] The rates of stroke were low and similar between the groups; however, relative to those who received a surgical valve, rates of major adverse cardiovascular/cerebral events were significantly better at 1 year and overall hemodynamic performance was better at all time points in those who underwent TAVR with CoreValve. [42]
In the ADVANCE study (ArmeD SerVices TrAuma RehabilitatioN OutComE), Linke et al found that implantation of a self-expanding transcatheter aortic valve system (CoreValve System) resulted in a significant improvement in hemodynamics and an increase in the effective aortic valve orifice area in high-risk patients with severe aortic stenosis. [43] Major adverse cardiovascular and cerebrovascular events were 8.0% at 30 days and 21.2% at 12 months; all-cause mortality was 4.5% and 17.9%, respectively; cardiovascular mortality was 3.4% and 11.7%, respectively; and rate of stroke was 3.0% and 4.5%, respectively. [43]
In a retrospective study (2007-2013) of data from 714 Canadian patients with severe aortic stenosis who underwent transfemoral TAVR to evaluate outcomes of balloon-expandable (n = 317) versus self-expandable (n = 397) transcatheter heart valves, investigators found no difference in mortality or all-cause readmission rates between the two groups. [44] However, the safety profile revealed patients in the balloon-expandable group had higher incidences of complications with vascular access sites, compared with those in the self-expandable group who were significantly more likely to suffer an inhospital stroke and have a need for a second transcatheter heart valve device or permanent pacemaker. [44]
Medical Treatment
The medical treatment options are limited in symptomatic patients with aortic stenosis who are not candidates for surgery. In patients with pulmonary congestion, cautious use of digitalis, diuretics, and angiotensin-converting enzyme (ACE) inhibitors might attempted, whereas beta-blockers might be used if the predominant symptom is angina. In any case, excessive decrease in preload or systemic arterial blood pressure should be avoided.
Vasodilators may be used for heart failure and for hypertension but should also be employed with extreme caution to avoid critically reducing preload or systemic arterial blood pressure in a patient with significant aortic stenosis.
Severe hypertension is frequently seen in the elderly patient with aortic stenosis and should be treated, because it causes an additional increase in vascular afterload. Treatment should follow the guidelines set out in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. [45] Reducing the blood pressure to normal levels is advisable, but hypotension must be avoided. [5]
The ESC/EACTS guidelines recommend that patients with heart failure symptoms who are not suitable candidates for surgery or transcatheter aortic valve implantation may be treated with digoxin, diuretics, ACE inhibitors, or angiotensin receptor blockers. [5]
Endocarditis prophylaxis
Antibiotic prophylaxis for the prevention of bacterial endocarditis is no longer recommended in patients with valvular aortic stenosis.
Activity
Patients with mild aortic stenosis can lead a normal life. In cases of moderate aortic stenosis, moderate to severe physical exertion and competitive sports should be avoided.
Prevention/Deterrence
Although small, observational studies have suggested that statin use can reduce aortic valve leaflet calcification and delay the progression of aortic stenosis severity, [46] 3 randomized, double-blind, placebo controlled trials of almost 2200 patients showed that intensive lipid-lowering therapy does not halt the progression of calcific aortic stenosis or induce its regression. [47, 48, 49]
Long-Term Monitoring
The frequency of the follow-up visits in asymptomatic patients is determined by the severity of aortic stenosis and by the presence of comorbid conditions.
In patients with mild aortic stenosis, yearly history and physical examination and an echocardiogram every 3-5 years are appropriate.
Patients with moderate or severe aortic stenosis should be examined twice yearly and whenever they develop symptoms that are potentially attributable to aortic stenosis.
In patients with moderate aortic stenosis, echocardiograms should be performed every 2 years, whereas in asymptomatic patients with severe aortic stenosis, yearly echocardiograms are recommended.
Following aortic valve replacement, every patient should undergo echocardiographic examination after recovery. Thereafter, an examination is recommended whenever new symptoms develop that are attributable to a potential valvular dysfunction.
Patients with mechanical valves should receive lifelong anticoagulation with warfarin and should undergo periodic screening of their anticoagulation status.
-
Stenotic aortic valve (macroscopic appearance).
Tables
Age < 70 years (n=324) |
Age >70 years (n=322) |
Bicuspid AV (50%) Postinflammatory (25%) Degenerative (18%) Unicommissural (3%) Hypoplastic (2%) Indeterminate (2%) |
Degenerative (48%) Bicuspid (27%) Postinflammatory (23%) Hypoplastic (2%) |
Severity |
Mean gradient (mmHg) |
Aortic valve area (cm2) |
Mild |
< 25 |
>1.5 |
Moderate |
25-40 |
1-1.5 |
Severe |
>40 |
< 1 (or < 0.5 cm2/m2 body surface area) |
Critical |
>80 |
< 0.5 |
Indication |
Class |
Symptomatic severe high-gradient AS (Stage D1) |
I |
Asymptomatic severe AS (Stage C2) with and LVEF < 50% |
I |
Severe AS (Stage C or D) undergoing other cardiac surgery |
I |
Asymptomatic, very severe AS (Stage C1, aortic velocity ≥5.0 m/s) and low surgical risk |
IIa |
| Asymptomatic, severe AS (Stage C1) and decreased expercise tolerance or an exercise fall in blood pressure | IIa |
| Symptomatic severe low flow/low gradient AS with reduced LVEF (Stage D2) with a low-dose dobutamine stress study with aortic velocity ≥4.0 m/s with a value are ≤1.0 cm2 at any dobutamine dose | IIa |
| Symptomatic severe low flow/low gradient AS (Stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic and anatomic data support valve obstruction as the most likely cause of symptoms | IIa |
| Moderate AS (Stage B) who are undergoing other cardiac surgery | IIa |
| Asymptomatic severe AS (Stage C1) with rapid disease progression and low surgical risk | IIb |
Intervention Selection |
AHA/ACC (2014) [6] |
ESC/EACTS (2012) [5] |
STS(2013) [56] |
Surgical AVR in patients with low or intermediate surgical risk |
Class I |
Class I |
|
Transcatheter aortic valve replacement (TAVR) for patients who have a prohibitive surgical risk and a predicted post-TAVR survival >12 mo |
Class I |
Class I |
Class I |
TAVR for patients who have high surgical risk |
Class IIa-Reasonable |
Class IIa-Reasonable |
|
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS |
Class III |
Class III |
|
Balloon aortic valvuloplasty (BAV) as a bridge to surgical AVR or TAVR in severely symptomatic patients |
Class IIb-Consider |
Class IIb-Consider |
Class IIa-Reasonable |
BAV as bridge to AVR in hemodynamically unstable patients with severe AS where immediate AVR is not feasible |
Class IIb-Consider |
Class IIa-Reasonable |
|
BAV in severely symptomatic patients where AVR is not an option for symptom relief |
Class IIb-Consider |
||
BAV as a palliative measure when surgery is contraindicated because of severe comorbidities |
Class IIb-Consider |
Class IIb-Consider |
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Guidelines
- 2021 ACC/AHA Valvular Heart Disease Clinical Practice Guidelines
- 2021 ESC/EACTS Management of Valvular Heart Disease (VHD) Clinical Practice Guidelines
- 2017 Multisociety Appropriate Use Criteria
- 2017 AHA/ACC Guidelines for the Management of Patients with Valvular Heart Disease
- 2014 Multisociety Guidelines for the Management of Valvular Heart Disease
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