Severe aortic stenosis — recognition, severity and definitive management

Diagnosis: severe symptomatic calcific aortic stenosis. The symptom triad (angina, syncope, heart failure) plus the bedside phenotype (pulsus parvus et tardus, ejection systolic murmur radiating to the carotids, soft A2, S4) and the echo thresholds together establish severe AS.^[1][2]

Severity grading (echo). Vmax at least 4 m/s or mean gradient at least 40 mmHg defines severe AS; the AVA is typically 1.0 cm2 or less (indexed 0.6 cm2/m2 or less) but is supportive rather than required. Very severe = Vmax at least 5 m/s or mean gradient at least 60 mmHg. Here all three agree. EF is preserved (55%) — this is not low-flow low-gradient AS. AVA was obtained by the continuity equation (AVA = CSA_LVOT × VTI_LVOT / VTI_aortic).^[1][2]

Symptom triad and prognosis. Classic AS triad — angina, syncope, heart failure — with a mean survival after symptom onset of 5, 3 and 2 years respectively in the classical series^[3], and a 1-year mortality of up to 50 percent without AVR.^[4] This patient has all three: he is high-risk and AVR must not be delayed.

Class I indication for AVR. Symptomatic severe AS is a Class I indication for aortic valve replacement. AVR is the only survival-modifying therapy — statins (SEAS, ASTRONOMER) and other medical therapy do not halt progression.^[1][2]

Heart-team decision — SAVR vs TAVI. Apply the 2020 ACC/AHA age cut-points: under 65 (or life expectancy over 20 yrs) SAVR, over 80 transfemoral TAVI, 65–80 either after shared decision-making. This 78-year-old is in the 65–80 band — either SAVR or transfemoral TAVI based on anatomy, comorbidity, frailty and life expectancy. The 2021 ESC/EACTS uses a 75-year cut-point (75 or over, high surgical risk, or unsuitable for surgery → TAVI). With favourable iliofemoral anatomy and his age, TAVI with a balloon-expandable or self-expanding valve would be typical.^[1][2]

Pre-operative work-up. ECG-gated cardiac CT for annular sizing, vascular access assessment and calcium burden (essential before TAVI); coronary angiography before valve surgery — recommended in men over 40 and postmenopausal women, and in anyone with known cardiovascular disease, suspected ischaemia or LV systolic dysfunction — to detect CAD needing concomitant CABG (with SAVR) or PCI; frailty assessment (the 4-item Essential Frailty Toolset was the strongest predictor of 1-year death after TAVI or SAVR in FRAILTY-AVR); bloods including BNP, renal function, and an anaemia screen.^[2]

Resuscitation / interim care. Avoid vasodilators (ACE-i, nitrates), aggressive diuresis and negative inotropes (beta-blockers, verapamil/diltiazem) — the LV is preload- and afterload-dependent. Treat AF promptly (losing the atrial kick can precipitate pulmonary oedema), ischaemia, anaemia and infection. Balloon aortic valvuloplasty as a bridge only if decompensation precludes definitive AVR.^[1]

Counselling and follow-up. Explain the procedure, prosthetic choice (TAVI = bioprosthetic, no lifelong anticoagulation but deterioration over years) and the conduction risk: in the Evolut low-risk trial a self-expanding valve needed a new pacemaker in 17.4 percent at 30 days versus 6.1 percent after surgery, whereas balloon-expandable TAVR in PARTNER 3 showed no significant difference from surgery in new pacemaker insertion. Counsel also on paravalvular leak and stroke. Post-procedure: lifelong surveillance echo; endocarditis precautions.^[5][6]