Hemodynamic Management in Aortic Stenosis

General Principles

• The American College of Cardiology recommends maintaining adequate cardiac output while avoiding hypotension, with careful titration of antihypertensive medications starting at low doses and gradually increasing as needed 1
• Renin-angiotensin system (RAS) blockers, such as ACE inhibitors or ARBs, are potentially advantageous due to their beneficial effects on LV fibrosis, improved control of hypertension, and reduction of dyspnea and improved effort tolerance 1

Medication Management

• Beta blockers are appropriate for patients with reduced ejection fraction, prior myocardial infarction, arrhythmias, or angina pectoris 1, 2, 3
• Diuretics should be used sparingly in patients with small LV chamber dimensions, and medications to use with caution include diuretics, non-dihydropyridine calcium channel blockers, and alpha blockers 1, 3
• Statin therapy is recommended for hyperlipidemia in patients with aortic stenosis, for cardiovascular risk reduction 4
• Antihypertensive therapy should be initiated at low doses and gradually titrated upward, with renin-angiotensin system (RAS) blockade (ACE inhibitors/ARBs) potentially advantageous 1, 2, 3

Diagnosis and Evaluation

• Echocardiography should evaluate maximum aortic velocity, mean aortic valve gradient, aortic valve area, paravalvular and valvular regurgitation, LV function, and geometry 5
• Low-flow, low-gradient AS requires dobutamine stress echocardiography to distinguish true-severe from pseudo-severe AS 6
• Characteristics defining severe aortic stenosis include:

7

Indications for Intervention

• Intervention is recommended for patients with symptoms (dyspnea, heart failure, angina, syncope) and severe AS 5
• Intervention is recommended when left ventricular ejection fraction (LVEF) is reduced (<50-55%) 6, 8, 9
• Intervention is recommended when there is rapid progression (velocity increase >0.3 m/s/year) 6, 10
• Intervention is recommended when there is very severe AS (velocity >5 m/s) 10
• Intervention is recommended when there are elevated BNP levels 10

Choice of Intervention

• For patients <65 years, SAVR is preferred 6, 11, 12
• For patients 65-75 years, SAVR is generally preferred over TAVR 6
• For patients 75-80 years, either SAVR or TAVR may be considered (individualized) 6
• For patients >80 years, TAVR is preferred 6
• For patients with STS-PROM >8%, TAVR is preferred 6, 5
• For patients with STS-PROM ≤8%, either SAVR or TAVR is appropriate 6, 5
• For patients requiring concomitant procedures (CABG, mitral valve surgery), SAVR is recommended 6, 5

Valve Selection

• For patients <50 years, a mechanical valve is recommended 6
• For patients 50-60 years, a mechanical valve is preferred over bioprosthetic 6
• For patients 60-65 years, either mechanical or bioprosthetic valve may be considered 6
• For patients >65 years, a bioprosthetic valve is recommended 6

Peri-Procedural Care

• Monitor access site for adequate hemostasis and normal distal blood flow 5
• Assess for potential complications requiring hemodynamic support, including valve embolization, paravalvular aortic regurgitation, coronary occlusion, annular rupture, shock, or hemodynamic collapse 5
• Have bailout strategies prepared for hemodynamic compromise, including inotropic support, mechanical circulatory support, and cardiopulmonary bypass 5

Post-Procedural Care and Follow-up

• Regular monitoring every 6 months with echocardiography is recommended for patients with severe AS, and every 12 months for moderate AS 4, 3
• Asymptomatic severe AS should be monitored every 6 months with echocardiography, to assess disease progression and guide treatment decisions 3
• Severe AS patients should be monitored every 6 months, and moderate AS patients should be monitored every 12 months, with regular imaging surveillance essential to monitor aortic diameter, and MRI being the preferred technique for follow-up studies 3, 13, 14
• Smoking cessation is critical, and moderate physical activity is recommended, while avoiding competitive sports to prevent blood pressure spikes 13
• Specific diameter thresholds for intervention include ≥45 mm for patients with Marfan syndrome, ≥50 mm for patients with bicuspid aortic valves, and ≥55 mm for other patients, and surgery should be considered with rapid increase in aortic diameter (≥5 mm per year), family history of aortic dissection, or presence of significant aortic regurgitation 13, 15

Special Considerations

• Urgent valve intervention (TAVR or SAVR) is the definitive treatment for patients with severe aortic stenosis and cardiogenic shock, with balloon aortic valvuloplasty (BAV) serving as a bridge to definitive therapy when immediate valve replacement is not feasible 9, 16
• TAVR may be considered as a bridge to definitive TAVR/SAVR in patients with need for urgent non-cardiac surgery 9
• Palliative care may be considered for patients with life expectancy <1 year or <25% chance of survival with benefit at 2 years 5
• A Heart Team approach, involving multiple specialists, is recommended for decision-making between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) 5, 17, 9