Table 15

Current Treatment Recommendations for Patients With Aortic Stenosis

TreatmentIndicationMajor Complications
Surgical Aortic Valve Replacement

  • • Symptomatic severe AS (Class I, LOE: B)

  • • Severe AS undergoing CABG, aortic surgery or other valve surgery (Class I, LOE: C)

  • • Symptomatic moderate AS undergoing CABG, aortic surgery or other valve surgery (Class IIa, LOE: C)

  • • Asymptomatic severe AS with hypotensive response to exercise (Class IIb; LOE: C)

  • • Asymptomatic extremely severe AS (AVA <0.6 cm2, mean gradient >50 mm Hg, or jet velocity >5 m/s) (Class IIb, LOE: C)

  • • Mortality (3%)

  • • Stroke (2%)

  • • Prolonged ventilation (11%)

  • • Thromboembolism and bleeding

  • • Prosthetic dysfunction

  • • Perioperative complications are higher when surgical AVR is combined with CABG

Transcatheter Aortic Valve Replacement

  • • TAVR is recommended in patients with severe, symptomatic, calcific stenosis of a trileaflet aortic valve who have aortic and vascular anatomy suitable for TAVR and a predicted survival >12 months, and who have a prohibitive surgical risk as defined by an estimated 50% or greater risk of mortality or irreversible morbidity at 30 days or other factors such as frailty, prior radiation therapy, porcelain aorta, and severe hepatic or pulmonary disease.

  • • TAVR is a reasonable alternative to surgical AVR in patients at high surgical risk (PARTNER Trial Criteria: STS≥8%⁎)

  • • Mortality (3% to 5%)

  • • Stroke (6% to 7%)

  • • Access complications (17%)

  • • Pacemaker insertion

    • ○ 2% to 9% (Sapien)

    • ○ 19% to 43% (CoreValve)

  • • Bleeding

  • • Prosthetic dysfunction

  • • Paravalvular AR

  • • Acute kidney injury

  • • Other

    • ○ Coronary occlusion

    • ○ Valve embolization

    • ○ Aortic rupture

Balloon Aortic Valvuloplasty

  • • Reasonable for palliation in adult patients with AS in whom surgical AVR cannot be performed because of serious comorbid conditions (Class IIb, LOE: C)

  • • Bridge to surgical AVR (Class IIb, LOE: C)

  • • Mortality

  • • Stroke

  • • Access complications

  • • Restenosis

Medical Therapy

  • • No specific therapy for asymptomatic AS

  • • Medical therapy not indicated for symptomatic severe AS

  • • Appropriate control of blood pressure and other risk factors as indicated

  • • Statins not indicated for preventing progression of AS

  • • Diuretics, vasodilators and positive inotropes should be avoided in patients awaiting surgery because of risk of destabilization

  • • Hemodynamic instability

Source of Class/LOE recommendations: Bonow et al. (28).

Class I: Conditions for which there is evidence for and/or general agreement that the procedure or treatment is beneficial, useful, and effective; Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment; Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy; Class IIb: Usefulness/efficacy is less well established by evidence/opinion; LOE B: Data derived from a single randomized trial or nonrandomized studies; LOE C: Only consensus opinion of experts, case studies, or standard-of-care.

AR indicates aortic regurgitation; AS, aortic stenosis; AVR, aortic valve replacement; CABG, coronary artery bypass graft; LOE, level of evidence; STS, Society of Thoracic Surgeons; and TAVR, transcatheter aortic valve replacement.

  • ↵⁎ The original PARTNER protocol specified inclusion criteria as a minimum STS-predicted risk of mortality of ≥10. During the trial enrollment phase, the minimum STS-predicted risk of mortality was changed to ≥8. In both instances, 2 surgeons had to document that the true predicted risk of mortality was ≥15.