Indications for valve replacement in aortic stenosis in adults
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
- Section Editors
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Edward Verrier, MD
Edward Verrier, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington School of Medicine
Surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) are the only effective treatments for severe aortic stenosis (AS). Recommendations for surgical valve replacement for AS are based upon comparisons of the natural history of patients with AS to outcomes after surgical aortic valve replacement (figure 1). Recommendations for TAVR for AS are based upon randomized trial and observational study data. (See "Natural history, epidemiology, and prognosis of aortic stenosis" and "Choice of prosthetic heart valve for surgical replacement" and "Choice of therapy for symptomatic severe aortic stenosis".)
Indications for surgical AVR and TAVR for AS and choice of procedure are discussed here .
Other issues relating to the surgical AVR and TAVR, the medical management of patients with AS, and valve surgery in elderly adults are discussed separately. (See "Choice of prosthetic heart valve for surgical replacement" and "Choice of therapy for symptomatic severe aortic stenosis" and "Medical management of asymptomatic aortic stenosis in adults" and "Medical management of symptomatic aortic stenosis" and "Valvular heart disease in elderly adults".)
APPROACH TO IDENTIFYING CANDIDATES FOR VALVE REPLACEMENT
The following are the key steps in determining whether a patient with aortic stenosis (AS) has an indication for valve replacement (algorithm 1):
●Identification of the patient’s symptom status
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Freeman RV, Otto CM. Spectrum of calcific aortic valve disease: pathogenesis, disease progression, and treatment strategies. Circulation 2005; 111:3316.
- Smith N, McAnulty JH, Rahimtoola SH. Severe aortic stenosis with impaired left ventricular function and clinical heart failure: results of valve replacement. Circulation 1978; 58:255.
- Murphy ES, Lawson RM, Starr A, Rahimtoola SH. Severe aortic stenosis in patients 60 years of age or older: left ventricular function and 10-year survival after valve replacement. Circulation 1981; 64:II184.
- Schwarz F, Baumann P, Manthey J, et al. The effect of aortic valve replacement on survival. Circulation 1982; 66:1105.
- Lund O. Preoperative risk evaluation and stratification of long-term survival after valve replacement for aortic stenosis. Reasons for earlier operative intervention. Circulation 1990; 82:124.
- Kouchoukos NT, Dávila-Román VG, Spray TL, et al. Replacement of the aortic root with a pulmonary autograft in children and young adults with aortic-valve disease. N Engl J Med 1994; 330:1.
- Horstkotte D, Loogen F. The natural history of aortic valve stenosis. Eur Heart J 1988; 9 Suppl E:57.
- Föppl M, Hoffmann A, Amann FW, et al. Sudden cardiac death after aortic valve surgery: incidence and concomitant factors. Clin Cardiol 1989; 12:202.
- Murphy ES, Kloster FE. Late results of valve replacement surgery. II. Complications of prosthetic heart valves. Mod Concepts Cardiovasc Dis 1979; 48:59.
- Bloomfield P, Kitchin AH, Wheatley DJ, et al. A prospective evaluation of the Björk-Shiley, Hancock, and Carpentier-Edwards heart valve prostheses. Circulation 1986; 73:1213.
- Hammermeister KE, Henderson WG, Burchfiel CM, et al. Comparison of outcome after valve replacement with a bioprosthesis versus a mechanical prosthesis: initial 5 year results of a randomized trial. J Am Coll Cardiol 1987; 10:719.
- Villari B, Vassalli G, Betocchi S, et al. Normalization of left ventricular nonuniformity late after valve replacement for aortic stenosis. Am J Cardiol 1996; 78:66.
- Connolly HM, Oh JK, Orszulak TA, et al. Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction. Prognostic indicators. Circulation 1997; 95:2395.
- Kang DH, Park SJ, Rim JH, et al. Early surgery versus conventional treatment in asymptomatic very severe aortic stenosis. Circulation 2010; 121:1502.
- Otto CM. Valvular aortic stenosis: disease severity and timing of intervention. J Am Coll Cardiol 2006; 47:2141.
- Das P, Rimington H, Chambers J. Exercise testing to stratify risk in aortic stenosis. Eur Heart J 2005; 26:1309.
- Amato MC, Moffa PJ, Werner KE, Ramires JA. Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing. Heart 2001; 86:381.
- McCann GP, Hillis WS. Surgery in asymptomatic aortic stenosis. BMJ 2004; 328:63.
- Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation 1997; 95:2262.
- Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation 2013; 128:873.
- Rafique AM, Biner S, Ray I, et al. Meta-analysis of prognostic value of stress testing in patients with asymptomatic severe aortic stenosis. Am J Cardiol 2009; 104:972.
- Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
- Pereira JJ, Lauer MS, Bashir M, et al. Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction. J Am Coll Cardiol 2002; 39:1356.
- Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
- Kvidal P, Bergström R, Hörte LG, Ståhle E. Observed and relative survival after aortic valve replacement. J Am Coll Cardiol 2000; 35:747.
- Gilard M, Cornily JC, Pennec PY, et al. Accuracy of multislice computed tomography in the preoperative assessment of coronary disease in patients with aortic valve stenosis. J Am Coll Cardiol 2006; 47:2020.
- Meijboom WB, Mollet NR, Van Mieghem CA, et al. Pre-operative computed tomography coronary angiography to detect significant coronary artery disease in patients referred for cardiac valve surgery. J Am Coll Cardiol 2006; 48:1658.
- Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), European Association for Percutaneous Cardiovascular Interventions (EAPCI), Wijns W, et al. Guidelines on myocardial revascularization. Eur Heart J 2010; 31:2501.
- Paradis JM, Fried J, Nazif T, et al. Aortic stenosis and coronary artery disease: what do we know? What don't we know? A comprehensive review of the literature with proposed treatment algorithms. Eur Heart J 2014; 35:2069.
- Gasparetto V, Fraccaro C, Tarantini G, et al. Safety and effectiveness of a selective strategy for coronary artery revascularization before transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2013; 81:376.
- Wenaweser P, Pilgrim T, Guerios E, et al. Impact of coronary artery disease and percutaneous coronary intervention on outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. EuroIntervention 2011; 7:541.
- Goel SS, Ige M, Tuzcu EM, et al. Severe aortic stenosis and coronary artery disease--implications for management in the transcatheter aortic valve replacement era: a comprehensive review. J Am Coll Cardiol 2013; 62:1.
- Goel SS, Agarwal S, Tuzcu EM, et al. Percutaneous coronary intervention in patients with severe aortic stenosis: implications for transcatheter aortic valve replacement. Circulation 2012; 125:1005.
- Fighali SF, Avendaño A, Elayda MA, et al. Early and late mortality of patients undergoing aortic valve replacement after previous coronary artery bypass graft surgery. Circulation 1995; 92:II163.
- Odell JA, Mullany CJ, Schaff HV, et al. Aortic valve replacement after previous coronary artery bypass grafting. Ann Thorac Surg 1996; 62:1424.
- Sundt TM 3rd, Murphy SF, Barzilai B, et al. Previous coronary artery bypass grafting is not a risk factor for aortic valve replacement. Ann Thorac Surg 1997; 64:651.
- Pereira JJ, Balaban K, Lauer MS, et al. Aortic valve replacement in patients with mild or moderate aortic stenosis and coronary bypass surgery. Am J Med 2005; 118:735.
- APPROACH TO IDENTIFYING CANDIDATES FOR VALVE REPLACEMENT
- Identification of patient's symptom status
- Identification of severe AS
- Assessment of left ventricular ejection fraction
- INDICATIONS FOR VALVE REPLACEMENT
- Symptomatic patients
- Asymptomatic severe aortic stenosis
- - Considerations
- - Left ventricular systolic dysfunction
- - Very severe AS
- - Role of exercise testing
- - Role of careful monitoring
- Low gradient aortic stenosis
- CHOICE OF SURGICAL OR TRANSCATHETER INTERVENTION
- Approach to choice of intervention for AS
- Choice of surgical valve replacement type
- CONCOMITANT CORONARY REVASCULARIZATION
- Candidates for aortic valve replacement who may require coronary revascularization
- - Coronary angiography prior to valve surgery
- Noninvasive coronary angiography
- - Revascularization and valve replacement
- Candidates for CABG who may require aortic valve replacement
- MEDICAL MANAGEMENT IN PATIENTS AWAITING SURGERY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS