Low-Flow/Low-Gradient AS: Intervention vs. No Intervention
A 74-year-old male patient with a medical history of permanent atrial fibrillation, nonischemic cardiomyopathy (left ventricular ejection fraction [LVEF] of 30%), hypertension, chronic kidney disease, and rib sarcoma s/p chemoradiation presented with fatigue and exertional dyspnea for 6 months. Coronary angiogram showed mild coronary artery disease. Echocardiography showed his calculated aortic valve area (AVA) was 0.9 cm2 (indexed AVA = 0.4 cm2) with peak gradient of 36 mmHg and mean gradient of 22 mmHg (averaged over 5 beats). He was referred for low-dose dobutamine stress echocardiogram, which showed an increase in aortic valve gradients to peak of 69 mmHg and mean of 41 mmHg (averaged over 5 beats) while AVA remained the same at 0.9 cm2. There was also an increase in stroke volume by 30%. The patient was evaluated by a multidisciplinary team and determined to be at intermediate risk for cardiovascular complications from aortic valve surgery.
What intervention would you recommend next?