Moderate Aortic Stenosis and Heart Failure With Reduced Ejection Fraction: Can Imaging Guide Us to Therapy?

JACC Cardiovasc Imaging. 2019 Jan;12(1):172-184. doi: 10.1016/j.jcmg.2018.10.021.

Abstract

Clinical management of patients with only moderate aortic stenosis (AS) but symptoms of heart failure with a reduced left ventricular ejection fraction (HFrEF) is challenging. Current guidelines recommend clinical surveillance with multimodality imaging; aortic valve replacement (AVR) is deferred until the stenosis becomes severe. Given the known benefits of afterload reduction in management of patients with HFrEF, it has been hypothesized that AVR may be beneficial in patients with only moderate AS who present with HFrEF. In this article, we first review the current approach for management of patients with moderate AS and HFrEF based on close clinical and imaging surveillance with AVR delayed until AS is severe. We then discuss the case for transcatheter AVR (TAVR) earlier in the disease course, when AS is moderate, based on stress echocardiographic data. We conclude with a detailed summary of the TAVR UNLOAD (Transcatheter Aortic Valve Replacement to UNload the Left Ventricle in Patients With ADvanced Heart Failure) trial, in which patients with moderate AS and HFrEF are randomized to guideline-directed heart failure therapy alone versus guideline-directed heart failure therapy plus TAVR.

Keywords: aortic stenosis; computed tomography; dobutamine stress echocardiography; systolic heart failure; transcatheter aortic valve replacement.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Aortic Valve Stenosis / complications
  • Aortic Valve Stenosis / diagnostic imaging*
  • Aortic Valve Stenosis / physiopathology
  • Aortic Valve Stenosis / therapy
  • Clinical Decision-Making*
  • Echocardiography*
  • Echocardiography, Doppler
  • Echocardiography, Stress
  • Echocardiography, Three-Dimensional
  • Echocardiography, Transesophageal
  • Heart Failure / diagnostic imaging*
  • Heart Failure / etiology
  • Heart Failure / physiopathology
  • Heart Failure / therapy
  • Humans
  • Magnetic Resonance Imaging
  • Multimodal Imaging
  • Patient Selection
  • Predictive Value of Tests
  • Prognosis
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Stroke Volume*
  • Tomography, X-Ray Computed*
  • Ventricular Dysfunction, Left / diagnostic imaging*
  • Ventricular Dysfunction, Left / etiology
  • Ventricular Dysfunction, Left / physiopathology
  • Ventricular Dysfunction, Left / therapy
  • Ventricular Function, Left*