When should intervention be considered for aortic stenosis and what are the treatment options?
Severe symptomatic aortic stenosis requires valve intervention given poor prognosis with medical management alone. Surgical aortic valve replacement (SAVR) remains the gold standard for low-surgical-risk patients. Transcatheter aortic valve implantation (TAVI/TAVR) is preferred for high-risk and many intermediate-risk patients, with expanding indications to lower-risk populations based on recent trial data.
Severity Assessment
Severe AS is defined by aortic valve area <1.0 cm², mean gradient >40 mmHg, or peak velocity >4.0 m/s. Low-flow, low-gradient AS requires careful evaluation with dobutamine stress echocardiography or CT calcium scoring. Asymptomatic severe AS warrants close surveillance; intervention may be considered with very severe stenosis, declining LVEF, or positive exercise testing.
Intervention Selection
Heart team evaluation integrates surgical risk scores, frailty assessment, anatomy, and patient preferences. SAVR is preferred for younger patients, bicuspid valves, and those requiring concomitant cardiac surgery. TAVI is established for prohibitive, high, and intermediate surgical risk. Low-risk trials (PARTNER 3, Evolut Low Risk) demonstrate non-inferiority of TAVI at 1-2 years.
Post-Intervention Management
Antiplatelet therapy post-TAVI typically includes dual therapy for 3-6 months in non-AF patients. Anticoagulation for AF patients continues with DOACs preferred. Paravalvular leak and conduction abnormalities require monitoring post-TAVI. Long-term valve durability data beyond 5-10 years remains limited for TAVI, influencing decisions in younger patients.
Points of Disagreement
TAVI versus SAVR for low-risk younger patients remains debated due to limited long-term durability data for transcatheter valves.
Multi-Guideline Agreement: High (88%)
Consensus Models: Gemini 3, Gemini 3 Pro, Sonnet 4.5, GPT 5.2
External Auditors: Grok 4, Opus 4.5
Last reconciled: December 31, 2025 | Version: 1.0