Aortic stenosis treatment in 2022

Abstract

When patients require treatment for aortic stenosis, the only option available is replacement of the aortic valve. The first aortic valve replacement took place in 1960 with a mechanical valve. Since then and along with all aspects of health care, valve surgery has undergone a continuous and very impressive development. At present, there are several options for prosthetic aortic valve replacement: the most popular ones are either mechanical or so called biologic (made of porcine aortic valves or bovine pericardium). Another alternative is the pulmonary autograft also known as the Ross operation, performed in specialized centers in a very small number of patients throughout the world. More recently introduced, transarterial aortic valve implantation or replacement (TAVI or TAVR) is a procedure in which an aortic valve bioprosthesis is implanted without replacing the native valve and also avoiding cardiopulmonary bypass. Initially intended for very old and inoperable patients, it is now being promoted for younger and low risk patients. Its role vs surgical valve replacement is a matter for controversy. Aortic valve replacement is associated with a normal life expectancy in patients over the age of 60. For younger ones this is only observed in those who have had a Ross operation. Surgical aortic valve replacement has also evolved in order to accelerate postoperative recovery by using minimally invasive approaches and the implementation of ultrafast track management that avoids postoperative mechanical ventilation and optimizes pain and blood management. At present, the best options for young patients would be a mechanical valve with optimal anticoagulation management or a Ross operation. For older patients, a conventional bioprosthesis should be used as the risk of prosthetic dysfunction is very low. TAVI is an alternative for very old or otherwise inoperable patients. In our part of the world there is still need for improvement in transparency and public reporting of results as well as providing detailed information on advantages and disadvantages of all the options. This should help patients make better decisions.