Current Management of Calcific Aortic Stenosis

Abstract

Calcific aortic stenosis is a progressive disease with no effective medical therapy that ultimately requires aortic valve replacement (AVR) for severe valve obstruction. Echocardiography is the primary diagnostic approach to define valve anatomy, measure aortic stenosis severity, and evaluate the left ventricular response to chronic pressure overload. In asymptomatic patients, markers of disease progression include the degree of leaflet calcification, hemodynamic severity of stenosis, adverse left ventricular remodeling, reduced left ventricular longitudinal strain, myocardial fibrosis, and pulmonary hypertension. The onset of symptoms portends a predictably high mortality rate unless AVR is performed. In symptomatic patients, AVR improves symptoms, improves survival, and, in patients with left ventricular dysfunction, improves systolic function. Poor outcomes after AVR are associated with low-flow low-gradient aortic stenosis, severe ventricular fibrosis, oxygen-dependent lung disease, frailty, advanced renal dysfunction, and a high comorbidity score. However, in most patients with severe symptoms, AVR is lifesaving. Bioprosthetic valves are recommended for patients aged >65 years. Transcatheter AVR is now available for patients with severe comorbidities, is recommended in patients who are deemed inoperable, and is a reasonable alternative to surgical AVR in high-risk patients.