Regardless of symptoms, your patients with severe aortic stenosis (AS) have a chance for optimal outcomes with TAVR—including low-risk and asymptomatic patients. Explore the eligibility of TAVR.2,3
Hank | Age 68: HG-LEF
Severe AS, asymptomatic
About Hank
Hank is a recent widower who volunteers at his local animal shelter on the weekends.
Medical history
Hank was diagnosed with severe AS but was not referred at the time due to his comorbidities. However, he was re-evaluated by a new cardiologist after his retired.
Comorbidities
Diabetes, CKD, and COPD
Medications
Metformin, sulfonylurea, empagliflozin, and tiotropium/olodaterol
AVR is associated with a survival benefit in patients with HG-LEF severe AS.6 Further, patients with C2 subtype have a class I indication for AVR in the ACC/AHA Guideline.1
All patients with severe AS should be referred for evaluation, regardless of symptom presentation.1
ACC=American College of Cardiology; AHA=American Heart Association; AS=aortic stenosis; AVR=aortic valve replacement; HG-LEF=high gradient, low ejection fraction.
Anne | Age 85: LG-LEF
Severe AS, symptoms include presyncope
About Anne
Anne is a colon cancer survivor who has never missed a monthly video chat with friends from her patient support group.
Medical history
Anne was diagnosed after being admitted to the emergency department upon feeling faint at a family dinner. She received an echo several years ago but AS was not identified; only gradient was considered.
Comorbidities
Atrial fibrillation, CKD, and hypertension
BP: 138/70 mmHg
Medications
Hydrochlorothiazide, amlodipine, metoprolol, and rivaroxaban
AVR is associated with a survival benefit in patients with LG-LEF symptomatic severe AS.6 Furthermore, TAVR is associated with improved survival in patients with symptomatic severe AS and CKD regardless of stage and protects from further decline in renal function over one year of follow-up.7-10 Patients with D2 LG subtype have a class I indication for AVR in the ACC/AHA Guideline.1
Comorbidities should not act as barriers to referring appropriate patients to a Heart Valve Team.11
ACC=American College of Cardiology; AHA=American Heart Association; AS=aortic stenosis; AVR=aortic valve replacement; CKD=chronic kidney disease; LG-LEF=low gradient, low ejection fraction.
Charles | Age 67: HG-NEF
Severe AS, symptoms include fatigue and dyspnea
About Charles
Charles is a former high school teacher and swim coach who recently retired after 42 years.
Medical history
Charles was diagnosed with moderate AS after a heart murmur was detected and received regular follow-up. He initially denied symptoms, but upon further questioning revealed that he stopped swimming for exercise because he felt tired and short of breath with even moderate exertion.
Comorbidities
Diabetic nephropathy and coronary artery disease
Medications
Metformin, sulfonylurea, simvastatin, and empagliflozin
AS=aortic stenosis; HG-NEF=high gradient, normal ejection fraction.
AVA
0.5 cm2
Gradient
52 mmHg
LVEF
66%
Peak velocity
4.3 m/s
Would you conduct further evaluation of this patient?
Further evaluation
Asking patients about changes in their activities and whether they’re continuing to participate in their hobbies can help uncover signs of progression to severe AS.12
AVR is associated with a survival benefit in patients with HG-NEF symptomatic severe AS.6 Patients with D1 subtype have a class I indication for AVR in the ACC/AHA Guideline.1
Comorbidities should not act as barriers to referring appropriate patients to a Heart Valve Team.11
ACC=American College of Cardiology; AHA=American Heart Association; AS=aortic stenosis; AVR=aortic valve replacement; HG-NEF=high gradient, normal ejection fraction.
Marie | Age 75: LG-NEF
Severe AS, symptoms include dyspnea
About Marie
Marie is a grandmother of 8 who enjoys hosting Sunday dinners for her family.
Medical history
Marie was diagnosed upon referral to a Heart Valve Team, where MSCT determined her calcium score was 1683 Agatston units. She received an echo previously, but AS was not indicated and gradient was noted as normal.
Comorbidities
Asthma and osteoporosis
Uses a walker due to hip fracture
Medications
Fluticasone inhaler, albuterol rescue inhaler, and alendronate
AS=aortic stenosis; LG-NEF=low gradient, normal ejection fraction; MSCT=multislice computed tomography.
AVA
0.9 cm2
Peak velocity
3.5 m/s
LVEF
70%
LVSVi
27 mL/m2
Gradient
25 mmHg
Would you conduct further evaluation of this patient?
Further evaluation
An LVSVi of <35 mL/m2 is required to make a diagnosis of LF-LG AS, whether the LVEF is preserved or reduced.1,13,14 Further, ACC/AHA Guideline recommends determining flow in patients with low-gradient disease to distinguish the severity of AS.1
ACC=American College of Cardiology; AHA=American Heart Association; AS=aortic stenosis; AVA=aortic valve area; LF-LG=low flow, low gradient; LG-NEF=low gradient, normal ejection fraction; LVEF=left ventricular ejection fraction; LVSVi=left ventricular stroke volume index.
Diagnosis:
Severe AS Stage D3
Low surgical risk
Treatment considerations
AVR is associated with a survival benefit in patients with LG-NEF symptomatic severe AS.6 Patients with D3 subtype have a class I indication for AVR in the ACC/AHA Guideline.1
Comorbidities should not act as barriers to referring appropriate patients to a Heart Valve Team.11
References:1.Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e72-e227.2.Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380(18):1695-1705.3.Généreux P, Schwartz A, Oldemeyer JB, et al. Transcatheter aortic-valve replacement for asymptomatic severe aortic stenosis. N Engl J Med. 2025;392(3):217-227.4.Généreux P, Banovic M, Kang DH, et al. Aortic valve replacement vs clinical surveillance in asymptomatic severe aortic stenosis: a systematic review and meta-analysis. J Am Coll Cardiol. 2025;85(9):912-922.5.Lindman BR, Pibarot P, Schwartz A, et al. Cardiac biomarkers in patients with asymptomatic severe aortic stenosis: analysis from the EARLY TAVR trial. Circulation. Published online March 31, 2025. doi:10.1161/CIRCULATIONAHA.125.0744256.Li SX, Patel NK, Flannery LD, et al. Trends in utilization of aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol. 2022;79(9):864-877.7.Mentias A, Desai MY, Saad M, et al. Management of aortic stenosis in patients with end-stage renal disease on hemodialysis. Circ Cardiovasc Interv. 2020;13(8):e009252.8.Steinmetz T, Witberg G, Chagnac A, et al. Transcatheter aortic valve implantation versus conservative treatment in chronic kidney disease patients. EuroIntervention. 2018;14(5):e503-e510.9.Bohbot Y, Candellier A, Diouf M, et al. Severe aortic stenosis and chronic kidney disease: outcomes and impact of aortic valve replacement. J Am Heart Assoc. 2020;9(19):e017190.10.Cubeddu RJ, Asher CR, Lowry AM, et al. Impact of transcatheter aortic valve replacement on severity of chronic kidney disease. J Am Coll Cardiol. 2020;76(12):1410-1421.11.Feldman DR, Romashko MD, Koethe B, et al. Comorbidity burden and adverse outcomes after transcatheter aortic valve replacement. J Am Heart Assoc. 2021;10(10):e018978.12.Otto CM. Timing of aortic valve surgery. Heart. 2000;84(2):211-218.13.Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr. 2017;30(4):372-392. 14.Hung J, Klassen SL, Bermejo J, Chambers JB. Take home messages with cases from focused update on echocardiographic assessment of aortic stenosis. Heart. 2018;104(16):1317-1322.
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TAVR by Edwards is now the FIRST and ONLY TAVR to be approved for the treatment of both symptomatic and asymptomatic patients with severe aortic stenosis, also known as heart valve failure.
