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AORTIC STENOSIS

Aortic Stenosis (AS) is the most common primary valve disease leading to surgery or catheter intervention in Europe and North America.1 It is present in approximately 2% of the general population with a rising prevalence in the elderly (up to 6% in patients above 85 years old).2-4

Symptomatic AS has significant effects on a patient’s health and quality of life5,6 and many will have cardiovascular and other comorbidities, for example, other valvular diseases, diabetes mellitus, hypertension and peripheral vascular disease.7-11

The 2021 European Society of Cardiology/European Association of Cardiothoracic Surgery (ESC/EACTS) Guidelines for the management of Valvular Heart Disease (VHD) stipulate that heart valve centers should promote timely referral of patients with VHD.18 Symptomatic severe AS has a dismal prognosis and guidelines strongly recommend early intervention in all patients.1,18

Treatment options for aortic stenosis:

MEDICAL MANAGEMENT

Medical treatment options for symptomatic patients with severe AS are limited. Medical treatment may be helpful in ameliorating symptoms in the short term but does not change the poor prognosis and natural history of severe AS.19
 

VALVE REPAIR

Surgical aortic valve repair in the setting of AS is currently only applied on a limited scale.20 Repair is most suitable for treatment of aortic regurgitation, rather than for stenosis, except for younger patients with a uni- or bicuspid valve.21,22
 

VALVE REPLACEMENT

Valve replacement is the only definitive treatment for severe, symptomatic AS. Surgical Aortic Valve Replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are both guideline-recommended treatments for severe, symptomatic AS:

  • SAVR: Younger patients who are low risk for surgery (<75 years and STS-PROM*/EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI.18
  • TAVI: Older patients (≥75 years), or in those who are high risk (STS-PROM*/EuroSCORE IIf >8%) or unsuitable for surgery.18
  •  SAVR or TAVI are recommended for remaining patients according to individual clinical, anatomical, and procedural characteristics.18
     

WATCHFUL WAITING

Watchful waiting may be a safe strategy for asymptomatic patients without risk factors predicting symptom development.1

It is recommended that patients with valvular heart disease should be managed through a multidisciplinary heart team comprising clinical and interventional cardiologists, cardiac surgeons, imaging specialists with expertise in interventional imaging, cardiovascular anaesthesiologists, and other specialists if necessary (e.g. heart failure specialists or electrophysiologists).18

The 2021 ESC/EACTS Guidelines for the management of VHD stipulate that the choice between surgical and transcatheter intervention must be based upon careful evaluation of clinical, anatomical, and procedural factors by the heart team, weighing the risks and benefits of each approach for an individual patient. The heart team recommendation should be discussed with the patient who can then make an informed treatment choice.18
 

*STS-PROM=Society of Thoracic Surgeons predicted risk of mortality

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References
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