Management of Aortic Stenosis

Diagnosis and Monitoring

Trace mitral regurgitation (MR) and tricuspid regurgitation (TR) are common incidental findings and generally benign, according to the European Society of Cardiology (ESC) guidelines 1, 2
Mild left ventricular hypertrophy (LVH) with normal left ventricular (LV) function suggests early adaptation to pressure load, and LVH in the context of mild aortic stenosis (AS) represents a compensatory mechanism 3
The European Society of Cardiology (ESC) guidelines recommend more frequent monitoring (every 1-2 years) if there are signs of progression, such as changes in aortic valve gradient and area, LV size and function, progression of LVH, development of symptoms (dyspnea, angina, syncope), or blood pressure control 2
Echocardiographic follow-up is recommended every 3-5 years for mild AS, with earlier reassessment if new symptoms develop, according to the ESC guidelines 2

Careful blood pressure management, with a target blood pressure <140/90 mmHg, is recommended by the American College of Cardiology, as hypertension can exacerbate LVH 1
Aggressive management of cardiovascular risk factors, including lipid control, diabetes management, smoking cessation, weight management, and regular physical activity, is essential for patients with mild AS, according to the American College of Cardiology 1
Future intervention would be warranted if AS progresses to severe (valve area <1.0 cm² or indexed valve area <0.6 cm²/m²), patient develops symptoms attributable to AS, LVEF decreases to <50-55%, or rapid progression of peak aortic jet velocity (>0.3 m/s/year), as recommended by the ESC guidelines 2

The presence of multiple mild valve lesions may have additive effects on LV remodeling, and monitoring for appropriate LV remodeling is important, according to the ESC guidelines 1
Surgery is indicated for all symptomatic patients with severe aortic regurgitation (AR) regardless of left ventricular (LV) function, and for asymptomatic patients with LV dysfunction (LVEF <50-55%) or significant LV dilation, as recommended by the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) 4, 5, 6
Intervention is indicated if left ventricular ejection fraction (LVEF) is declining to <55% without other cause, according to the European Society of Cardiology (ESC) 6
Abnormal exercise test showing symptoms clearly related to AS or AR is an indication for intervention, as recommended by the European Society of Cardiology (ESC) 5

Aortic valve replacement (AVR) is indicated if LVEF <50% (ACC/AHA) or <55% (ESC) when no other cause for LV dysfunction exists, as recommended by the ESC and ACC/AHA 4
AVR is reasonable when LVESD >50 mm (Class I) or >45 mm (Class IIa), as recommended by the ESC 4
Replacement of aortic sinuses/ascending aorta is reasonable when aortic dimension is ≥45 mm, as recommended by the ESC 4
Valve-sparing surgery may be considered in patients with bicuspid aortic valve (BAV) at comprehensive valve centers, according to the ESC 4
Surgical AVR (mechanical or bioprosthetic valve) is the standard intervention, according to the ESC 4
Aortic valve repair may be considered in selected patients with favorable valve anatomy at experienced centers, as recommended by the ESC 4
Transcatheter aortic valve implantation (TAVI) may be considered in experienced centers for selected patients ineligible for surgical AVR, as recommended by the ESC 4

Antihypertensive treatment is recommended for asymptomatic patients with chronic AR and hypertension (systolic BP >140 mmHg), as recommended by the ESC 4
Guideline-directed medical therapy (GDMT) with ACE inhibitors, ARBs, and/or sacubitril/valsartan is recommended for patients with symptoms and/or LV dysfunction but prohibitive surgical risk, according to the ESC 4
Medical therapy (ACE inhibitors or dihydropyridines) may provide symptomatic improvement in patients with severe AR when surgery is not feasible, as recommended by the ESC 4

Severe asymptomatic AR: Every 6-12 months, as recommended by the ESC 4
If significant fall in LVEF or increase in LV size is observed: Every 3-6 months, according to the ESC 4
Moderate AR: Every 1-2 years, as recommended by the ESC 4
Mild AR: Every 3-5 years, according to the ESC 4
Echocardiographic follow-up is recommended every 3-5 years for mild AS, with earlier reassessment if new symptoms develop, according to the ESC guidelines 2