Approach to the patient with aortic stenosis and low ejection fraction

Aortic stenosis is the most common valvular abnormality in the United States today. It has been well established that most patients with severe symptomatic aortic stenosis should undergo operation with aortic valve replacement. This is particularly true when ventricular function is maintained, as the operative risk is low and the long-term outcome is excellent. In most patients with a reduced ejection fraction, there is an increased risk of operation and poorer long-term outcome. However, operation is still of benefit in most patients, as relief of an afterload mismatch will improve ventricular function and provide symptom relief. There is a subset of patients with left ventricular dysfunction at even higher risk who have a low aortic valve gradient and small valve area, some of whom may not have severe obstruction. Pharmacologic challenge may be necessary to identify those patients with true aortic stenosis and further helps determine those who would benefit from surgical intervention.