In severe symptomatic AS, early intervention is recommended in all patients except if the chance for improvement in the quality of life or survival due to other comorbidities is low or if there is the presence of a co-existing disease for which the survival chance is < 1 year.
In cases of symptomatic severe high gradient AS, regardless of LVEF, intervention is recommended.
When severe AS is confirmed by echocardiography, intervention is recommended.
In low-grade symptomatic AS:
Low flow, low gradient, reduced EF due to excessive afterload: LV function improves after intervention.
Low flow, low gradient, reduced LVEF caused by scarring due to myocardial infarction or cardiomyopathy: improvement after intervention is uncertain.
Symptomatic patients with severe low flow, low gradient AS, reduced EF, and evidence of flow reserve should be considered for intervention.
Symptomatic low flow, low gradient, and normal EF: intervention should be considered after accurate confirmation that AS is severe.
Symptomatic low flow, low gradient, reduced EF, severe AS, without flow reserve—and when CCT calcium scoring confirms severe AS, intervention should be considered.
Low flow, low gradient, and preserved EF: regular clinical and echocardiographic surveillance is recommended.
Low flow, low gradient, and preserved EF: Intervention is to be considered only when the patient is symptomatic or when there is a significant valve obstruction.
In pseudo-severe symptomatic AS, conventional heart failure treatment
Asymptomatic AS:
Asymptomatic, severe AS, impaired LV function (<50%) of no other cause: intervention is recommended.
Asymptomatic, severe AS, impaired LV function (<55%) of no other cause: intervention should be considered.
Asymptomatic during normal activities but becomes symptomatic during exercise testing: intervention is recommended.
No adverse prognostic features: watchful waiting is recommended until symptoms onset; immediate intervention
Asymptomatic, severe AS, sustained reduction in BP (>20 mmHg) during exercise testing: intervention should be considered.
Consider intervention if the patient is asymptomatic, LVEF > 55%, normal exercise test, procedure risk is low, and one of the following exists:
Very severe AS: mean gradient >=60 mmHg or Vmax >5 m/s).
Severe valve calcification (assessed by CCT) and Vmax progression >=0.3 m/s/year.
Remarkable elevation in BNP levels (>3 age- and sex-corrected normal range) was confirmed by repeated measurements and without other explanation.
Mode of Intervention:
Intervention should be done at heart valve centers that:
Declare their local expertise and outcome data.
Have an active interventional cardiologist and surgical program on-site.
Structured collaborative heart team approach.
The decision about the intervention (surgical vs. transcatheter) should be made after:
Full evaluation of anatomical, clinical, and procedural factors.
Risk vs. benefit analysis of each approach
Discuss the recommendation with the patient.
Surgical aortic valve replacement (SAVR) is recommended in:
Young patients (<75 years) with low surgical risk (STS-PROM/EuroSCORE II <4%)
Patients who are operable but not fit for transfemoral transcatheter aortic valve implantation procedure (TAVI)
TAVI is recommended for:
older adults ( >=75 years).
High-risk patients (STS-PROM/EuroSCORE II >8%)
Patients who are not fit surgically
For the remaining patients, the decision is made based on their clinical, anatomical, and procedural characteristics; TAVI and SAVR are recommended.
Inoperable patients who are unsuitable for transfemoral TAVI may consider non-transfemoral TAVI.
Hemodynamically unstable patients and severe AS cases that require urgent non-cardiac surgery may consider balloon aortic valvotomy as a bridge to SAVR or TAVI.
For patients with severe AS undergoing coronary artery bypass graft surgery (CABG) or any surgical intervention to the ascending aorta or any other valve: SAVR is recommended.
Patients with moderate AS undergoing coronary artery bypass graft surgery (CABG) or any surgical intervention to the ascending aorta or any other valve: SAVR should be considered after Heart team discussion.
Heart failure patients who are not fit for either SAVR or TAVI should be treated according to HF guidelines.
ACEI’s class has a myocardial benefit in AS before symptoms onset.
Co-existing hypertension should be controlled to avoid additional afterload.
No endocarditis prophylaxis is required in symptomatic patients with no previous history of infective endocarditis.
Because AS is a predisposing factor for developing endocarditis, patients should be educated about proper dental hygiene.
Therapy should be continued in patients with coronary artery disease and AFIB, whether symptomatic or asymptomatic.
Rate control and anticoagulation are adequate goals for patients with AFIB.
Notes:
Vascular complications, pacemaker implantation, and para-valvular regurgitation are higher after TAVI.
Severe bleeding, acute kidney injury (AKI), and new-onset AFIB are more common post-SAVR.
.webp)
.webp)
.webp)
.webp)
.webp)
.webp)