valve-replacement

(Circ 2021;143:e72)

• Based on symptoms: once they develop → AVR needed
• Indicated in: sx severe (stage D1; D2; D3 if AS felt to be cause of sx); asx severe + EF <50% (stage C2); or severe (stage C1) and undergoing other cardiac surgery
• Reasonable if: asx severe (C1) but either sx or ↓ BP w/ exercise (can carefully exercise asx AS to uncover sx; do not exercise sx AS), very severe, ↑ BNP, rapid progression
• Growing data to support AVR in asx severe AS (NEJM 2020;382:111; Circ 2021;143:e72)
• Type of valve: mechanical reasonable if Pt <50 yrs, bioprosthetic if >65 yrs or cannot tolerate long-term anticoagulation; individualize if 50–65 yrs
• Transcatheter AoV implantation (TAVI, see below) attractive alternative to surgery
• Medical (if not AVR candidate or to temporize): careful diuresis prn, control HTN, maintain SR; digoxin if ↓ EF & HF or if AF; avoid venodilators (nitrates) & ⊖ inotropes (βB/CCB) if severe AS; avoid vigorous physical exertion once AS mod–severe ? nitroprusside (w/ PAC) in HF w/ sev. AS, ↓ EF/CO, & HTN (Circ 2013;128:1349)
• IABP: stabilization, bridge to surgery
• Balloon valvotomy (now rare): ↑ AVA, but risk CVA/AR & restenosis; ∴ bridge or palliation