Treatment of aortic stenosis

Treatment goals for aortic stenosis:

• Prevention of sudden death and heart failure.
• Relief of disease symptoms and improvement of quality of life.

Indications for surgical treatment of aortic stenosis

Class I

• AVR is indicated in symptomatic patients with severe aortic stenosis (level of evidence B).
• AVR is indicated in patients with severe aortic stenosis undergoing coronary artery bypass grafting (CABG) (level of evidence C).
• AVR is indicated for patients with severe aortic stenosis undergoing surgical interventions on the aorta and/or other heart valves (level of evidence C).
• AVR is recommended for patients with severe aortic stenosis and left ventricular systolic dysfunction (level of evidence C).

Class IIa

• AVR is justified in patients with moderate to severe aortic stenosis during CABG or surgical interventions on the aorta and other heart valves (level of evidence B).

Class IIb

• AVR may be considered in asymptomatic patients with severe aortic stenosis and paradoxical response to exercise (eg, symptomatic or asymptomatic hypotension) (Evidence Level C).
• AVR may be performed in adults with severe asymptomatic aortic stenosis if there is a risk of rapid disease progression (age, calcification, and coronary artery disease) or if it is not possible to perform AVR in a timely manner when symptoms appear (level of evidence C).
• AVR may be considered in patients with mild aortic stenosis during CABG if there is a risk of rapid disease progression, such as the presence of moderate or severe calcification (level of evidence C).
• AVR may be performed in asymptomatic patients with critical aortic stenosis (aortic orifice area less than 0.6 cm2 ^, mean gradient greater than 60 mmHg, flow velocity greater than 5.0 m/s) if the expected mortality is 1.0% or less (evidence level C).

Class III

The use of AVR to prevent sudden death in asymptomatic patients is of no benefit unless the features listed in classes IIa and IIb of recommendations are present (level of evidence B).

Predictors of poor outcome after aortic valve replacement for aortic stenosis:

• Old age (over 70 years).
• Female gender.
• Urgent surgical intervention.
• Ischemic heart disease.
• Previous coronary artery bypass grafting.
• Hypertension.
• Left ventricular dysfunction (ejection fraction less than 40 or 50%).
• Heart failure.
• Atrial fibrillation.
• Simultaneous replacement or plastic surgery of the mitral valve.
• Renal failure.

Drug treatment of aortic stenosis

Prescribed to inoperable patients due to concomitant pathology. The choice of conservative tactics in patients with calcified aortic stenosis is very limited:

• beta-blockers (if the aortic valve orifice area is >0.8 cm2 ⁾ and nitrates (with caution) - for angina pectoris;
• digoxin (for atrial tachyarrhythmia and/or ejection fraction of 25-30% and below);
• diuretics (with caution, in case of CHF);
• ACE inhibitors (careful dose titration).

In the case of pulmonary edema, sodium nitroprusside is indicated to reduce congestion and improve left ventricular function in the intensive care unit. Class III antiarrhythmic drugs are prescribed in the case of atrial fibrillation after ineffective cardioversion to control the ventricular rate.