Risk stratification and management of aortic stenosis with concomitant left ventricular dysfunction

Aortic stenosis is a common clinical problem. The development of symptoms usually precedes the development of left ventricular (LV) dysfunction. Therefore, patients with concomitant severe aortic stenosis and LV dysfunction comprise a minority with this condition, albeit a clinically challenging group to manage. Because the only proven therapy for aortic stenosis is surgical valve replacement, the approach to the management of a patient with aortic stenosis and LV dysfunction primarily centers on risk stratification and the decision of whether to operate. Patients with aortic stenosis and low transvalvular gradients constitute a distinctly high-risk group, particularly when evidence of contractile reserve is absent after challenge with dobutamine. In the absence of any effective medical therapies, it is increasingly clear that even high-risk patients lacking contractile reserve may benefit from surgical valve replacement. However, evolving experimental percutaneous solutions may offer new management options for high-risk patients in the future.