Aortic stenosis resident survival guide: Difference between revisions

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{{WikiDoc CMG}}; {{AE}} {{AL}}; {{Rim}}
{{WikiDoc CMG}}; {{AE}} {{AL}}
 
 
{{SK}} AS; critical AS; tight AS; aortic valve stenosis; calcific aortic stenosis; senile calcific aortic stenosis; degenerative calcific aortic stenosis


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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Aortic stenosis resident survival guide#Causes|Causes]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Aortic stenosis resident survival guide#Causes|Causes]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Aortic stenosis resident survival guide#Diagnosis|Diagnosis]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Aortic stenosis resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Aortic stenosis resident survival guide#Choice of Intervention|Treatment]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Aortic stenosis resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Aortic stenosis resident survival guide#Treatment|Treatment]]
: [[Aortic stenosis resident survival guide#General Approach|General Approach]]
: [[Aortic stenosis resident survival guide#Choice of Intervention|Choice of Intervention]]
: [[Aortic stenosis resident survival guide#Choice of Intervention|Choice of Intervention]]
: [[Aortic stenosis resident survival guide#Type of Valve and Discharge Anticoagulation Therapy|Type of Valve and Discharge Anticoagulation Therapy]]
: [[Aortic stenosis resident survival guide#Type of Valve and Discharge Anticoagulation Therapy|Type of Valve and Discharge Anticoagulation Therapy]]
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==Overview==
==Overview==
[[Aortic stenosis]] is the progressive narrowing of the diameter of the [[aortic valve]] (normal valve area is 3 - 4 cm²) and symptoms are caused by a decrease in stroke volume that leads to decrease perfusion to peripheral tissues, however, symptoms normally appear when the stenosis is ≤ 1.0 cm². The most common etiology of [[aortic stenosis]] is [[calcific aortic valve disease]].  The management will depend if the patient is symptomatic or asymptomatic.  Surgical intervention is the treatment of choice for patients with symptomatic [[aortic stenosis]].
[[Aortic stenosis]] is the progressive narrowing of the diameter of the [[aortic valve]] (normal valve area is 3 - 4 cm²).  The symptoms are caused by a decrease in the [[stroke volume]] which  reduces blood flow to peripheral tissues. The most common etiology of aortic stenosis is [[calcific aortic valve disease]].  The management of [[aortic stenosis]] depends on the stage of the disease which is determined by whether the patient is symptomatic or asymptomatic, the area of the valve, and the hemodynamic consequences of the stenosis.


==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Aortic stenosis is a progressive disease and does not have a life threatening cause.
* [[Infective Endocarditis]]


===Common Causes===
===Common Causes===
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* [[Rheumatic fever]]
* [[Rheumatic fever]]
* [[bicuspid aortic stenosis|Congenital bicuspid aortic valve]]  
* [[bicuspid aortic stenosis|Congenital bicuspid aortic valve]]  
* [[Endocarditis]]


==Diagnosis==
Click '''[[Aortic stenosis causes|here]]''' for the complete list of causes.
Shown below is an algorithm summarizing the diagnostic approach to [[aortic stenosis]] based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease <ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
 
==FIRE: Focused Initial Rapid Evaluation==
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref><br>
<span style="font-size:85%">Boxes in the red signify that an urgent management is needed.</span><br>
 
<span style="font-size:85%">'''Abbreviations:''' '''AVR:''' [[Aortic valve replacement]]; '''CK-MB:''' [[Creatine kinase myocardial type]]; '''ECG''': [[Electrocardiogram]]; '''NSTEMI:''' [[Non ST elevation myocardial infarction]]; '''STEMI:''' [[ST elevation myocardial infarction]]; '''TTE:''' [[Transthoracic echocardiography]] </span>
 
{{Family tree/start}}
{{familytree  | | | | | | | A00 | | | | | | | | | A00=<div style="width:22em">'''Identify cardinal findings that increase the pretest probability of aortic stenosis'''</div><br><div style="width:22em; text-align:left">❑ [[Systolic ejection murmur]]
:❑ Crescendo-decrescendo
:❑ Associated with an ejection click
:❑ Best heard at the upper right sternal border
:❑ Bilateral radiation to the [[carotid arteries]]
:❑ Increases with squatting and [[expiration]]
:❑ Decreases with [[valsalva maneuver]]
❑ [[Pulsus parvus et tardus]] (a weak and slow upstroke of the carotid waveform is an excellent indicator of aortic stenosis severity)<br>
❑ [[Narrow pulse pressure]]</div> }}
{{familytree  | | | | | | | |!| | | | | | | | | | }}
{{familytree  | | | | | | | A01 | | | | | | | | | | A01= <div style="text-align: left; width: 18em; padding: 1em;">'''Does the patient have any of the following findings require urgent management?'''<br>
❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br> ❑ [[Dyspnea|Severe dyspnea]]<br> ❑ [[Loss of consciousness]]<br>❑ [[Chest pain]]</div>}}
{{familytree  | | | | |,|-|-|^|-|-|.| | | | |}}
{{familytree  |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | B01 | | | | | B02 | | | |B01={{fontcolor|#F8F8FF|'''Yes'''}}| B02=<div style="text-align: center; background: #FFFFFF; height: 25px; line-height: 25px;">'''No'''</div>}}
{{familytree  | | | | |!| | | | | |!| }}
{{familytree  |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | |!| | | | | | C02 | | C02=<div style="text-align: center; background: #FFFFFF; height: 77px; line-height: 30px; padding: 5px;">'''Proceed to the<br>[[Aortic stenosis resident survival guide#Complete Diagnostic Approach| complete diagnostic approach]] below'''</div> }}
{{familytree  | | | | |!| | | | | | | }}
{{familytree  | | | |,|^|-|-|-|-|-|-|.| | | |}}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| | | R01 | | | | | | R02 | | | R01= The patient has a condition that exacerbates AS| R02= The patient has a decompensated AS causing complications}}
{{familytree  | |,|-|^|-|.| | | |,|-|^|-|.| |}}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| H01 | | H02 | | H03 | | H04 | | H01=<div style=" text-align: center; width:15em">'''[[Atrial fibrillation|<span style="color:white;">Atrial fibrillation</span>]]'''</div><br><div style=" text-align: left"> ❑ Suspect if there are [[palpitations|<span style="color:white;">palpitations</span>]] <br> ❑ Order an [[ECG|<span style="color:white;">ECG</span>]] immediately looking for
:❑ Irregularly irregular rhythm, and
:❑ Absent P waves
</div> |H02=<div style=" text-align: center; width:15em">[[Acute coronary syndrome|<span style="color:white;">'''Acute coronary syndrome'''</span>]]</div><br> <div style=" text-align: left"> ❑ Suspect if there is severe [[chest pain|<span style="color:white;">chest pain</span>]] <br>❑ Order an [[ECG|<span style="color:white;">ECG</span>]] immediately<br>
❑ Order [[troponin|<span style="color:white;">troponin </span>]] and [[CK-MB|<span style="color:white;">CK-MB</span>]]
</div>|H03= <div style=" text-align: center; width: 15em">[[syncope|<span style="color:white;">'''Syncope'''</span>]]</div> <br><div style=" text-align: left"> ❑ Suspect if there is loss of consciousness of:
: ❑ Short duration
: ❑ Rapid onset
: ❑ Complete spontaneous recovery</div>| H04=<div style=" text-align: center; width:15em">'''[[Acute heart failure|<span style="color:white;">Acute heart failure</span>]]'''</div><br><div style=" text-align: left">❑ Suspect if there are:
:❑ Severe [[dyspnea|<span style="color:white;">dyspnea</span>]]<br>
:❑ Signs of volume overload </div>}}
{{familytree  | |!| | |!| | | | | |!| | |!| | | | }}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| J01| |J02 | | J03 | | J04 | | | | | | | | | J01= <div style=" background: #FA8072; text-align: left; width: 15em">[[Atrial fibrillation resident survival guide|<span style="color:white;">'''Click here for atrial fibrillation resident survival guide'''</span>]] </div> | J02= <div style=" background: #FA8072; text-align: left; width: 15em">[[STEMI resident survival guide|<span style="color:white;">'''Click here for STEMI resident survival guide'''</span>]], or<br>[[Unstable angina/ NSTEMI resident survival guide|<span style="color:white;">'''Click here for NSTEMI resident survival guide'''</span>]] </div> | J03=<div style=" background: #FA8072; text-align: left; width: 15em">[[Syncope resident survival guide|<span style="color:white;">'''Click here for syncope resident survival guide'''</span>]] </div>|J04=<div style=" background: #FA8072; text-align: left; width: 15em">[[Acute decompensated heart failure resident survival guide#First Initial Rapid Evaluation of Suspected Acute Heart Failure|<span style="color:white;"> '''Click here for acute heart failure resident survival guide'''</span>]] </div>}}
{{familytree  | |L|~|~|A|~|~|V|~|~|A|~|~|J| | |}}
{{familytree  | | | | | | | |:| | | | | | | | |}}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | | G01 | | | | G01= <div style=" background: #FA8072; text-align: left; width: 20em"> {{fontcolor|#F8F8FF| ❑ Treat the complications of [[aortic stenosis|<span style="color:white;">aortic stenosis</span>]] that lead to decompensation <br> ❑ Order a [[TTE|<span style="color:white;">TTE</span>]] to evaluate the severity of the [[aortic stenosis|<span style="color:white;">aortic stenosis</span>]] <br> ❑ Do not give [[nitrates|<span style="color:white;">nitrates</span>]] (could cause severe [[hypotension|<span style="color:white;">hypotension</span>]])<br> ❑ Monitor vital signs continuously}} </div>}}
{{familytree  | | | | | | | |!| | }}
{{familytree  |boxstyle=background: #FA8072; color: #F8F8FF;| | | | | | | H01 | | | | | | | | | H01=<div style=" background: #FA8072; text-align: left; width: 20em"> {{fontcolor|#F8F8FF| Does the patient improve with medical therapy?}}</div> }}
{{familytree  | | | | | |,|-|^|-|.|}}
{{familytree  |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | I01 | | I02 | | I01= <div style=" background: #FA8072; text-align: center; width:20em"> {{fontcolor|#F8F8FF|'''No'''}} </div> | I02=<div style="padding: 5px; background: #FFFFFF; text-align: center;">'''Yes'''</div>}}
{{familytree  | | | | | |!| | | |!| | | }}
{{familytree  |boxstyle= padding: 0; background: #FA8072; text-align: center;| | | | | J01 | | J02 | | J01= <div style=" background: #FA8072; text-align: left; width:20em; padding:1em"> {{fontcolor|#F8F8FF|❑ Proceed with urgent [[AVR|<span style="color:white;">AVR</span>]]}} </div> | J02= <div style="padding: 5px; background: #FFFFFF; text-align: center;">'''[[Aortic stenosis resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div> }}
{{Family tree/end}}
<br><br>
 
==Complete Diagnostic Approach==


<span style="font-size:85%">'''Abbreviations:''' '''LVH:''' Left ventricle hypertrophy; '''CXR:''' Chest x-ray; '''ECG:''' Electrocardiogram; '''LBBB:''' Left bundle branch block; '''AF:''' Atrial fibrillation; '''AVR:''' Aortic valve replacement; '''VHD:''' Valve heart disease; '''TAVR:''' Transcatheter aortic valve replacement; '''TTE:''' Transthoracic echocardiography </span>
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
 
<span style="font-size:85%">'''Abbreviations:''' '''AS:''' [[Aortic stenosis]]; '''AF:''' [[Atrial fibrillation]]; '''AVR:''' [[Aortic valve replacement]]; '''CXR:''' [[Chest X-ray]]; '''ECG:''' [[Electrocardiogram]]; '''LBBB:''' [[Left bundle branch block]]; '''LVH:''' [[LVH|Left ventricle hypertrophy]]; '''TAVR:''' [[Transcatheter aortic valve replacement]]; '''TTE:''' [[Transthoracic echocardiography]]; '''VHD:''' [[Valvular heart disease]] </span>
<br>
<br>
{{Family tree/start}}
{{Family tree/start}}
{{family tree | | | | | V01 | | | | | | | | | | | | | | | |V01= <div style="float: left; text-align: left; line-height: 150%; width: 25em">'''Characterize the symptoms:''' <br>
{{family tree | | | | | V01 | | | | | | | | | | |V01= <div style="float: left; text-align: left; line-height: 150%; width: 25em">'''Characterize the symptoms:''' <br>
Most patients are asymptomatic <br> ❑ [[Dyspnea]] on exertion <br> Exertional [[dizziness]] <br> Exertional [[angina]] <br> ❑ [[Syncope]] <br> ❑ [[Chest pain]] <br> ❑ [[Palpitations]] </div> }}
[[Chest pain]], angina-type pain ''(Left untreated, the average survival is 5 years after the onset of angina in the patient with AS)''
{{family tree | | | | | |!| | | | | | | | | | | | | | | | }}
:❑ The pain is crushing, squeezing, pressure or tightness in nature
{{Family tree | | | | | Y01 | | | | | | | | | | | | | | | | Y01=<div style="float: left; text-align: Left; width:25em ">'''Inquire about past medical history:''' <br> ❑ Previously healthy <br> ❑ [[Cardiac disease]]: <br>
:❑ The pain increases with [[exercise]], relieved with rest
:❑ Pain under the chest bone, it may move to other areas
❑ [[Syncope]]'' (Left untreated, the average survival is 3 years after the onset of syncope in the patient with AS)'' <br>
Symptoms suggestive of [[congestive heart failure]] ''(Left untreated, the average survival is 1 years after the onset of heart failure in the patient with AS)''
:❑ [[Dyspnea on exertion]]
:❑ [[Fatigue]]
:❑ [[Orthopnea]]
:❑ [[Paroxysmal nocturnal dyspnea]]
:❑ [[Pulmonary edema]]
:❑ [[Pulmonary hypertension]] that can lead to:
::❑ [[Right ventricular failure]]
::❑ [[Hepatomegaly]]
::❑ [[Atrial fibrillation]]
::❑ [[Peripheral edema]]
::❑ [[Tricuspid regurgitation]]
❑ [[Palpitations]]
</div> }}
{{family tree | | | | | |!| | | | | | | | | | | }}
{{Family tree | | | | | Y01 | | | | | | | | | | Y01=<div style="float: left; text-align: Left; width:25em ">'''Inquire about past medical history:''' <br>❑ [[Cardiovascular disease]] <br>
: ❑ [[Hypertension]]
: ❑ [[Hypertension]]
: ❑ [[Bicuspid aortic valve]]
: ❑ [[Bicuspid aortic valve]]
❑ [[Rheumatic fever]]  <br> ❑ [[Pulmonary disease]] </div> }}
❑ [[Rheumatic fever]]  <br> ❑ [[Pulmonary disease]] </div> }}
{{family tree | | | | | |!| | | | | | | | | | | | | | | | }}
{{family tree | | | | | |!| | | | | | | | | | | }}
{{Family tree | | | | | A01 | | | | | | | | | | | | | | | A01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient''': <br>
{{Family tree | | | | | A01 | | | | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:''' <br>
'''Vitals'''<br>
'''Vitals'''<br>
❑ [[Heart rate]]
❑ [[Heart rate]]
: ❑ Rhythm and rate are normal in most cases
: ❑ Normal rhythm and rate (in most cases)
: ❑ Arrhythmic (suggestive of [[AF]] in late stage disease)
: ❑ Irregularly irregular rhythm (suggestive of [[AF]] in late stage disease)
❑ [[Blood pressure]]
❑ [[Blood pressure]]
: ❑ [[Narrow pulse pressure]]
: ❑ [[Narrow pulse pressure]] (<25 mmHg)
Respiratory rate:
: ❑ Mild [[hypertension]] in moderate stenosis
: ❑ [[Hypotension]] in severe stenosis
Respiratory rate
: ❑ Normal in most cases
: ❑ Normal in most cases
: ❑ [[Tachypnea]] (suggestive of [[HF]])
: ❑ [[Tachypnea]] (suggestive of [[HF]])
----
<br>
'''Cardiovascular'''<br>
'''Cardiovascular examination'''<br>
❑ [[Cardiac palpation]]<br>
❑ [[Cardiac palpation]]<br>
: ❑ [[Apical impulse]] (suggestive of [[LVH]])<br>
: ❑ [[Apical impulse]] (suggestive of [[LVH]])<br>
: ❑ [[Systolic thrill]]<br>
: ❑ [[Palpable thrill]]<br>
❑ Pulses<br>
❑ Pulses<br>
: ❑ [[Pulsus parvus et tardus]]<br>
: ❑ [[Pulsus parvus et tardus]]<br>
: ❑ [[Pulsus bisferiens]] (suggestive of mixed [[aortic stenosis]] and [[aortic insufficiency|regurgitation]])
: ❑ [[Pulsus bisferiens]] (suggestive of mixed [[aortic stenosis]] and [[aortic insufficiency|regurgitation]])
❑ [[Cardiac auscultation]]<br>
❑ [[Cardiac auscultation]]<br>
: ❑ Crescendo-decrescendo [[heart murmur|systolic ejection murmur]] with ejection click<br>
: ❑ [[Murmur]]
: ❑ Best heard at the upper right sternal border<br>
:: ❑ Crescendo-decrescendo [[heart murmur|systolic ejection murmur]] with ejection click<br>
: ❑ Bilateral radiation to the [[carotid arteries]]<br>
:: ❑ Best heard at the upper right sternal border<br>
: ❑ Murmur increases with: squatting, [[expiration]]<br>
:: ❑ Bilateral radiation to the [[carotid arteries]]<br>
: ❑ Murmur decreases with [[valsalva maneuver]]<br>
:: ❑ Murmur increases with squatting and [[expiration]]<br>
:: ❑ Murmur decreases with [[valsalva maneuver]]<br>
<small>Click on the video below to listen to an aortic stenosis murmur. </small>
{{#ev:youtube|MJg257pyt4I|200}} <br>
{{#ev:youtube|MJg257pyt4I|200}} <br>
❑ Heart sounds:  
: [[Heart sounds]]
: ❑ Normal [[S1]]  
:: ❑ Normal [[S1]]  
: ❑ [[Paradoxical splitting of S2]] (not seen in early disease)
:: ❑ [[Paradoxical splitting of S2]] (in severe disease)
: ❑ [[S3]] may be present (suggestive of [[LVH]])
:: ❑ [[S3]] (suggestive of [[LVH]])
----
<br>
'''Respiratory'''<br>
'''Respiratory examination'''<br>
❑ [[Rales]] (suggestive of [[congestive heart failure]])
❑ [[Rales]] (suggestive of [[congestive heart failure]])
----
 
<br>
'''Extremities'''<br>
'''Extremities'''<br>
❑ [[Peripheral edema]] (suggestive of [[congestive heart failure]])  
❑ [[Peripheral edema]] (suggestive of [[congestive heart failure]])  
</div> }}
</div> }}
{{family tree | | | | | |!| | | | | | | | | | | | | | | | }}
{{family tree | | | | | |!| | | | | | | | | | | }}
{{Family tree | | | | | B01 | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: Left; width:25em "> '''Order imaging and adjuvant studies:''' <br>
{{Family tree | | | | | B01 | | | | | | | | | | B01=<div style="float: left; text-align: Left; width:25em ">'''Order tests:''' <br>
 
❑ '''[[TTE]]''' (most important evaluation test) ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]) <br>
: ''Assess the following:''
: ❑ Valve morphology
: ❑ Pressure gradient
: ❑ [[Aortic valve area]]
: ❑ [[Ejection fraction]]
: ❑ [[Left ventricle]] wall thickness and motility <br>
❑ [[ECG]] (shows non-specific findings):
❑ [[ECG]] (shows non-specific findings):
: ❑ [[LVH]]
: ❑ [[LVH]]
[[File:LVH-ECG.jpg|center|100px]]
: ❑ [[Left atrium]] enlargement
: ❑ Left [[atrium enlargement]]
[[File:LAE-2.png|center|200px]]
: ❑ [[LBBB]]
: ❑ [[LBBB]]
[[File:Left bundle branch block ECG characteristics.png|center|150px]]
: ❑ [[AF]] (in late disease)  
: ❑ [[AF]] (in late disease)  
❑ [[CXR]]:
❑ [[Chest X-ray]]:
: ❑ [[Cardiomegaly]]
: ❑ [[Cardiomegaly]]
[[File:LVH X ray.jpg|center|200px]]
: ❑ [[calcific aortic valve disease|Valve calcification]]
: ❑ [[calcific aortic valve disease|Valve calcification]]
: ❑ Dilatation of [[ascending aorta]]
: ❑ Dilatation of [[ascending aorta]]
: ❑ [[pulmonary edema|Pulmonary congestion]]
: ❑ [[pulmonary edema|Pulmonary congestion]]
  </div>}}
  </div>}}
{{family tree | | | | | |!| | | | | | | | | | | | | | | | }}
{{family tree | | | | | |!| | | | | | | | | | | }}
{{Family tree | | | | | Z01 | | | | | | | | | | | | | | Z01=<div style="float: left; text-align: Left; width:25em ">'''Order an [[TTE]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]) <br> ❑ Assess the following:
{{Family tree | | | | | Z01 | | | | | | | | | | Z01=<div style="float: left; text-align: left; width:25em "> '''Classify [[aortic stenosis]] based on the following findings on [[TTE]]:'''<br> ❑ Valve area (cm²) <br> ❑ Transvalvular pressure gradient (mmHg) <br> ❑ Aortic Vmax (m/s) </div>}}
: ❑ Valve morphology
{{Family tree | |,|-|-|-|+|-|-|v|-|-|-|.| | | | | |}}
: ❑ Pressure gradient
{{Family tree |C01 | | C02 | |C03 | | C04| | | | |C01=<div style="float: left; text-align: center; width:15em">'''No stenosis'''</div> <div style="float: left; text-align: left"><br> ❑ Valve area 2.5-3.5 cm² <br> ❑ No pressure gradient across the valve <br> ❑ Aortic Vmax <2 m/s</div> |C02=<div style="float: left; text-align: center; width:25em">'''Mild stenosis'''</div><div style="float: left; text-align: left"><br> ❑ Valve area 1.5-2.5 cm² <br> ❑ Pressure gradient ≤ 25 mmHg <br> ❑ Aortic Vmax 2.0-2.9 m/s </div>|C03=<div style="float: left; text-align: center; width:15em">'''Moderate stenosis'''</div><div style="float: left; text-align: left"><br> ❑ Valve area 1.0-1.5 cm² <br> ❑ Pressure gradient 25-40 mmHg <br> ❑ Aortic Vmax 3.0-3.9 m/s </div>|C04=<div style="float: left; text-align: center; width:15em">'''Severe stenosis'''</div><div style="float: left; text-align: left"><br> ❑ Valve area ≤ 1.0 cm² <br> ❑ Pressure gradient ≥ 40 mmHg <div style="font-size:85%">(except for stages D2 and D3, low flow low gradient)</div> ❑ Aortic Vmax 4 m/s</div>}}
: ❑ [[Aortic valve area]]
: ❑ [[Ejection fraction]]
: ❑ LV wall thickness and motility <br>
'''Interpret results from [[echocardiography|echo]]'''</div>}}
{{Family tree | |,|-|-|-|+|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C01 | | C02 | | | | | | C03 | | | | | | |C01=<div style="float: left; text-align: left; width: 12em line-height: 150% "> '''No stenosis''' ([[Aortic stenosis stages|Stage A]]) <br> ❑ Valve area 2.5-3.5 cm² <br> ❑ No pressure gradient </div> | C02=<div style="float: left; text-align: left; line-height: 150% ">'''Mild to moderate stenosis''' ([[Aortic stenosis stages|Stage B]]) <br> '''Mild:''' <br> ❑ Valve area 1.5-2.5 cm² <br> ❑ Pressure gradient ≤ 25 mmHg <br> '''Moderate:''' <br> ❑ Valve area 1.0-1.5 cm² <br> ❑ Pressure gradient 25-40 mmHg </div> | C03= <div style="float: left; text-align: left; width: 15em; line-height: 150% ">'''Severe stenosis''' <br> ❑ Valve area ≤ 1.0 cm² <br> ❑ Pressure gradient ≥ 40 mmHg </div>}}
{{family tree | |!| | | |!| | | | | |,|-|^|-|-|-|-|.| | | |}}
{{Family tree | D01 | | D02 | | | | D03 | | | | | D04 | | | |D01=<div style="float: left; text-align: left; width: 12em; line-height: 150% "> ❑ Normal valve <br> ❑ [[Bicuspid aortic valve|Bicuspid valve]] <br> ❑ [[Aortic sclerosis|Sclerotic valve]] </div>| D02=<div style="float: left; text-align: left; line-height: 150% "> ❑ '''Control [[Hypertension medical therapy|hypertension]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])<br> ❑ '''Perform a periodic [[echocardiogram]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence:B]]) <br>
: ❑ Every 3 -5 years for mild stenosis
: ❑ Every 1 - 2 years for moderate stenosis </div>
| D03= '''Asymptomatic''' <br> ([[Aortic stenosis stages|Stage C]])| D04= '''Symptomatic''' <br> ([[Aortic stenosis stages|Stage D]]) }}
{{family tree | |!| | | |:| | | | | |!| | | | | | |!| | | | }}
{{family tree | |!| | | |:| | | | | |!| | | | | | R01| | | | R01= <div style="text-align:left">If patient is unstable: <br> ❑ Administer vasodilation therapy with invasive hemodynamic monitoring ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: C]]) </div>}}
{{family tree | |!| | | |:| | | |,|-|^|-|.| | | |,|^|-|.| }}
{{Family tree | E01 | | E00 | | E02 | | E03 | |E04| |E05| | E01= <div style="float: left; text-align: left; width: 12em; line-height: 150% "> '''Control [[Hypertension medical therapy|hypertension]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])  </div>| E00= <div style=" text-align: left"> If patient undergoes another [[cardiac surgery]]: <br> ❑ '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: C]]) </div>|E02= '''Normal LVEF''' <br> ([[Aortic stenosis stages|Stage C1]])| E03= '''LVEF < 50%''' <br> ([[Aortic stenosis stages|Stage C2]]) | E04= '''High gradient (ΔP ≥ 40 mmHg)''' <br> ([[Aortic stenosis stages|Stage D1]]) | E05=<div style="float: left; text-align: left; width: 20 em "> '''Low gradient (ΔP ≤ 40 mmHg)''' <br> ❑ Normal [[LVEF]] ([[Aortic stenosis stages|Stage D2]]) <br> ❑ LVEF < 50% ([[Aortic stenosis stages|Stage D3]]) </div> }}
{{family tree | | | | | | | | | |!| | | |`|v|-|'| | | |!| | | | }}
{{Family tree | | | | | | | |  F01 | | | F02 | | | | F03 | | |F01= <div style=" text-align:left; width: 15em"> '''Perform a periodic echocardiogram every 6 - 12 months''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]) </div>  | F02= '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]]) | F03=<div style="float: left; text-align: left; width: 18em; line-height: 150% "> '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B-C]])</div>}}
{{family tree | | | | | | | | | |!| | | | | | | | | | | | | | }}
{{family tree | | | | | | | |  G01 | | | | | | | | | | | | | |G01= <div style=" text-align:left; width: 15em">  If aortic velocity 5 m/s or decrease in exercise tolerance: <br> ❑ '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]) </div>}}


{{familytree/end}}
{{familytree/end}}


==Choice of Intervention==
==Treatment==
===Indications for Aortic Valve Replacement===
'''Shown below is an algorithm depicting the indications for [[aortic valve replacement]] (AVR).  If the patient does not meet any of the decision pathways in the algorithm, regular monitoring is recommended and AVR is not indicated.'''<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>


Shown below is an algorithm summarizing the choice of the intervention to [[aortic stenosis]] based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease <ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
<span style="font-size:85%">'''Abbreviations:''' '''AVR:''' [[Aortic valve replacement]]; '''LVEF:''' [[Left ventricular ejection fraction]]; '''ΔP<sub>mean</sub>:''' mean pressure gradient; '''V<sub>max</sub>:''' maximum velocity</span>
<br>
 
{{Familytree/start}}
{{Family tree | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= '''Abnormal aortic valve'''<br> '''AND''' <br>'''Reduction in systolic opening'''}}
{{Family tree | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | }}
{{Family tree | | | | | B01 | | | | | | | | | | | B02 | | | | | | B01= '''Severe aortic stenosis:''' <br> '''V<sub>max</sub>≥4m/s'''<br> AND <br>'''ΔP<sub>mean</sub>≥40 mmHg''' | B02= '''V<sub>max</sub>3-3.9 m/s'''<br>AND <br>'''ΔP<sub>mean</sub>20-39 mmHg''' }}
{{Family tree | | | | | |!| | | | | | | | | | | | |!| | | | | | | }}
{{Family tree | | | | | C01 | | | | | | | | | | | C02 | | | | | | C01= Is the patient symptomatic?| C02= Is the patient symptomatic?}}
{{Family tree |,|-|-|-|-|^|-|-|-|.| | | | | |,|-|-|^|-|-|.| | | | }}
{{Family tree | D01 | | | | | | D02 | | | | D03 | | | | D04 | | | D01= Yes<br> ''(Stage D1)''| D02= No <br> ''(Stage C)''| D03= Yes| D04= No<br> ''(Stage B)''}}
{{Family tree |!| | | | | | | | |`|-|.| | | |!| | | | | |!| | | | }}
{{Family tree |!| | | | | | | | | | |!| | | |!| | | | | |!| | | | }}
{{Family tree |!|,|-|-|-|-|-|-| E01 |(| | | E02 | | | | E03 | | | E01= [[LVEF]] <50%<br> ''(Stage C2)''| E02= Is [[LVEF]] <50%?| E03= The patient is undergoing<br> another cardiac surgery}}
{{Family tree |!|!| | | | | | | | | |!| |,|-|^|-|.| | | |!| | | }}
{{Family tree |!|!|,|-|-|-|-|-| F01 |(| F02 | | F03 | | |!| | | | F01= The patient is undergoing <br>another cardiac surgery | F02= Yes| F03= No}}
{{Family tree |!|!|!| | | | | | | | |!| |!| | | |!| | | |!| | | }}
{{Family tree |!|!|!| | |,|-|-| G01 |(| G02 | | G03 | | |!| | | | G01= V<sub>max</sub>≥5m/s<br> AND <br>ΔP<sub>mean</sub>≥60 mmHg<br>''(Very severe stage C1)''<br> AND<br> Low surgical risk | G02= [[Dobutamine stress echocardiography]]: <br> Aortic valve area ≤1 cm<sup>2</sup> <br> AND <br> V<sub>max</sub>≥4 ms <br> ''(Stage D2)''| G03= Aortic valve area ≤1 cm<sup>2</sup> <br> AND <br> [[LVEF]] ≥50% <br> ''(Stage D3)''}}
{{Family tree |!|!|!| | |!| | | | | |!| |!| | | |!| | | |!| | | }}
{{Family tree |!|!|!| | |!|,|-| H01 |(| |!| | | H02 | | |!| | | | H01= Abnormal exercise treadmill test | H02= The symptoms are likely<br> the result of the [[aortic stenosis]]}}
{{Family tree |!|!|!| | |!|!| | | | |!| |!| | | |!| | | |!| | }}
{{Family tree |!|!|!| | |!|!| | I01 |'| |!| | | |!| | | |!| | I01= ΔV<sub>max</sub>>0.3 m/s/y <br> AND <br> Low surgical risk }}
{{Family tree |!|!|!| | |!|!| | |!| | | |!| | | |!| | | |!| | }}
{{Family tree | J01 | | J02 | | J03 | | J04 | | J05 | | J06 | J01= [[AVR]] ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])| J02= [[AVR]] ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]])| J03= [[AVR]] ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]])| J04= [[AVR]] ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]])| J05= [[AVR]] ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]])| J06= [[AVR]] ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]])}}
{{Family tree/end}}


{{Family tree/start}}
===Choice of Intervention===
{{family tree | | | | | | | A01 | | | | | | | | A01=<div style="float: left; text-align: center; width: 20em; padding:1em;"> '''Patient scheduled for [[AVR]]''' </div>  }}
Shown below is a table summarizing the choice of [[aortic valve replacement]] among patients with [[aortic stenosis]] based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease <ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
{{family tree | | | |,|-|-|-|^|-|-|-|.| | | | | }}
{{family tree | | | B01 | | | | | | B02 | | | | B01= '''High risk'''| B02= '''Low to moderate risk'''}}
{{family tree | | | |!| | | | | | | |!| | | | | }}
{{family tree | | | C01 | | | | | | C02 | | | | | C01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> ❑ A multidisciplinary group of physicians with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should decide intervention (Surgical [[AVR]] or [[transcatheter aortic valve implantation|TAVR]]) ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]) <br> ❑ Schedule for [[transcatheter aortic valve implantation|'''TAVR''']] ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref> <ref name="SmithLeon2011">{{cite journal|last1=Smith|first1=Craig R.|last2=Leon|first2=Martin B.|last3=Mack|first3=Michael J.|last4=Miller|first4=D. Craig|last5=Moses|first5=Jeffrey W.|last6=Svensson|first6=Lars G.|last7=Tuzcu|first7=E. Murat|last8=Webb|first8=John G.|last9=Fontana|first9=Gregory P.|last10=Makkar|first10=Raj R.|last11=Williams|first11=Mathew|last12=Dewey|first12=Todd|last13=Kapadia|first13=Samir|last14=Babaliaros|first14=Vasilis|last15=Thourani|first15=Vinod H.|last16=Corso|first16=Paul|last17=Pichard|first17=Augusto D.|last18=Bavaria|first18=Joseph E.|last19=Herrmann|first19=Howard C.|last20=Akin|first20=Jodi J.|last21=Anderson|first21=William N.|last22=Wang|first22=Duolao|last23=Pocock|first23=Stuart J.|title=Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients|journal=New England Journal of Medicine|volume=364|issue=23|year=2011|pages=2187–2198|issn=0028-4793|doi=10.1056/NEJMoa1103510}}</ref></div> | C02=<div style="float: left; text-align: left; width: 25em; padding:1em;"> ❑ Schedule for '''surgical [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]]) </div> }}


{{familytree/end}}<br>
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center | '''Choice of AVR''' || style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Indications'''
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Surgical AVR''' ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |- [[Aortic stenosis resident survival guide#Evaluation of Surgical and Interventional Cardiac Risk|Low or intermediate surgical risk]]
([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]])
|-
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Tansthoracic aortic valve replacement (TAVR)'''||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |- [[Aortic stenosis resident survival guide#Evaluation of Surgical and Interventional Cardiac Risk|Prohibitive surgical risk]] and a predicted post-TAVR survival >12 month ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])
- [[Aortic stenosis resident survival guide#Evaluation of Surgical and Interventional Cardiac Risk|High surgical risk]] ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])
|-
|}


===Evaluation of Surgical and Interventional Cardiac Risk===
===Evaluation of Surgical and Interventional Cardiac Risk===


Shown below is a table to assess the surgical and interventional risk which combines the STS risk estimate, frailty, major organ system dysfunction and procedure-specific impediments.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000029}}</ref>
Shown below is a table to assess the surgical and interventional risk which combines the Society of Thoracic Surgeons (STS) risk estimate, frailty, major organ system dysfunction and procedure-specific impediments.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000029}}</ref>


{| class="wikitable" border="1"
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
! style="width: 200px;background: #4479BA"| !! style="width: 250px;background: #4479BA"|{{fontcolor|#FFF| Low risk}} !! style="width: 250px;background: #4479BA;"|{{fontcolor|#FFF|Intermediate risk}} !! style="width: 250px;background: #4479BA;"|{{fontcolor|#FFF|High risk}} !! style="width: 250px;background: #4479BA;"|{{fontcolor|#FFF|Prohibitive risk}}
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''STC Predicted Risk of Mortality Score'''<ref name="STS">{{Cite web  | last =  | first =  | title = Online STS Risk Calculator | url = http://riskcalc.sts.org/ | publisher =  | date =  | accessdate = 7 March 2014 }}</ref>
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Frailty'''*
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Major organ system compromised without postoperative improvement'''
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Specific procedural impediment'''**
|-
|-
| style="width: 200px;background: #4479BA"|{{fontcolor|#FFF|'''STS PROM'''}} || <4% <br>''AND'' || 4% to 8% <br>''OR'' || >8% <br>''OR'' || Predicted risk of death or major morbidity (all-cause) >50% at 1 year <br>''OR''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Low risk''' <br> (Must meet ''ALL'' criteria in this row)||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | <4% || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |None || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |None || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |None
|-
|-
| style="width: 200px;background: #4479BA"|{{fontcolor|#FFF|'''Frailty*'''}} || None <br>''AND'' || 1 index <br>''OR'' || ≥2 indices (moderate to severe) <br>''OR'' || Predicted risk of death or major morbidity (all-cause) >50% at 1 year <br>''OR''
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Intermediate risk''' <br> (Must meet ''ANY'' criteria in this row)|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | 4% to 8%  ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | 1 index (mild)||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | 1 organ system ||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Possible
|-
|-
| style="width: 200px;background: #4479BA"|{{fontcolor|#FFF|'''Major organ system compromise not to be improved postoperatively'''}} || None <br>''AND'' || 1 organ system <br>''OR'' || No more than 2 organ systems <br>''OR'' || ≥3 organ systems <br>''OR''
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''High risk''' <br> (Must meet ''ANY'' criteria in this row)|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | >8%  || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |≥2 indices (moderate to severe)  || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |No more than 2 organ systems || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Possible
|-
|-
| style="width: 200px;background: #4479BA"|{{fontcolor|#FFF|'''Procedure-specific impediment**'''}} || None <br>|| Possible procedure-specific impediment || Possible procedure-specific impediment || Severe procedure-specific impediment
| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Prohibitive risk''' <br> (Must meet ''ANY'' criteria in this row)|| style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |>50% of predicted risk of death or major morbidity at 1 year || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |>50% of predicted risk of death or major morbidity at 1 year  || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |≥3 organ systems  || style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |Severe
|}
|}
'''STS PROM:''' Society of Thoracic Surgeons Predicted Risk of Mortality Score.<ref name="STS">{{Cite web  | last =  | first =  | title = Online STS Risk Calculator | url = http://riskcalc.sts.org/ | publisher =  | date =  | accessdate = 7 March 2014 }}</ref><br>
'''*Seven frailty indices''': Katz Activites of Daily Living (self-sufficient in feeding, bathing, dressing, transferring, toileting and urinary continence) and self-sufficient in deambulation (no walking aid or assist required or 5-meter walk in <6 s).<br>
'''**Procedure-specific impediment examples:''' tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall or radiation damage.


==Type of Valve and Discharge Anticoagulation Therapy==
'''*Seven frailty indices''': Katz Activites of Daily Living (self-sufficient in feeding, bathing, dressing, transferring, toileting, and urinary continence) and self-sufficient in deambulation (no walking aid or assist required or 5-meter walk in <6 s).<br>
'''**Examples of specific procedural impediment:''' tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall or radiation damage.
 
===Type of Valve and Discharge Anticoagulation Therapy===
<span style="font-size:85%">'''Abbreviations:''' '''AVR:''' Aortic valve replacement; '''INR:''' International normalized ratio; '''TAVR''' Tansthoracic aortic valve replacement </span>
 
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | | A01= <div style="float: left; text-align: left; width: 18em; padding:1em;">❑ '''Determine the age of the patient''' <br> ❑ '''Check for contraindications for anticoagulation''' </div>}}
{{Family tree | | | | | | | A01 | | | | | A01= <div style="float: left; text-align: left; width: 18em; padding:1em;"> '''Determine:''' <br> ❑ '''Age''' <br> ❑ '''Contraindications for anticoagulation'''<span style="font-size:80%">
{{Family tree | | | |,|-|-|-|^|-|-|-|.| | |}}
: ❑ Major [[bleeding diathesis]] or [[coagulopathy]]
{{Family tree | | | B01 | | | | | | B02 | | |  B01=<div style="float: left; text-align: left; width: 18em; padding:1em;"> ❑ Patients ≤ 70 years old ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]), and <br> ❑ No contraindication for anticoagulation </div>| B02= <div style="float: left; text-align: left; width: 18em; padding:1em;"> ❑ Patients ≥ 70 years old ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]), or <br> ❑ Patients with anticoagulant therapy contraindications ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]) </div> }}
: ❑ Uncontrolled severe hypertension ([[systolic blood pressure]] >200 mmHg)
: ❑ Recent [[head trauma]]
: ❑ Platelet count < 100 000
: ❑ [[Pregnancy]]
: ❑ Hypersensitivity to [[warfarin]]
: ❑ [[Hemorrhagic stroke]]</span></div>}}
{{Family tree | | | |,|-|-|-|+|-|-|-|.| | |}}
{{Family tree | | | B01 | | B03 | | B02 | | |  B01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients ≤ 60 years old <br> ''AND'' <br> ❑ No contraindication for anticoagulation ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div>| B03= <div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients 60 - 70 years old <br> ''AND'' <br> ❑ No contraindication for anticoagulation</div> | B02= <div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients ≥ 70 years old ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])<br> ''OR'' <br> ❑ Patients at any age AND contraindications for anticoagulation therapy ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]) </div> }}
{{Family tree | | | |!| | | |!| | | |!| | | }}
{{Family tree | | | |!| | | C00 | | |!| | | C00='''[[Aortic stenosis surgery procedure#Types of Valves|Bioprosthesic]]''' <br> OR <br> '''[[Aortic stenosis surgery procedure#Types of Valves|Mechanical prosthesis]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])}}
{{Family tree | | | |!|,|-|-|^|-|-|.|!| | | }}
{{Family tree | | | C01 | | | | | | C02 | | | C01= '''[[Aortic stenosis surgery procedure#Types of Valves|Mechanical prosthesis]]''' <br> <div style="float: left; text-align: left; width: 15em; padding:1em;"><span style="font-size:80%;color:red"> Avoid the use of direct thrombin inhibitors or anti-Xa agents in patients with mechanical prosthesis ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]]) </span></div>|C02='''[[Aortic stenosis surgery procedure#Types of Valves|Bioprosthesis]]'''}}
{{Family tree | | | |!| | | | | | | |!| | | }}
{{Family tree | | | |!| | | | | | | |!| | | }}
{{Family tree | | | C01 | | | | | | C02 | | | C01= '''[[Aortic stenosis surgery procedure#Types of Valves|Mechanical Prosthesis]]'''| C02= '''[[Aortic stenosis surgery procedure#Types of Valves|Bioprosthesis]]'''}}
{{Family tree | | | C04 | | | | | | C05 | | C04= Does the patient have risk factors for thromboembolism†?| C05= '''Surgical [[AVR]]''' <br> OR <br> '''[[Transcatheter aortic valve implantation|TAVR]]'''}}
{{Family tree | |,|-|^|-|.| | | |,|-|^|-|.| }}
{{Family tree | |,|-|^|-|.| | | |,|-|^|-|.| }}
{{Family tree | D01 | | D02 | | D03 | | D04 | | D01= <div style="float: left; text-align: center; width: 14em; padding:1em;"> Patient with risk factors </div> | D02=<div style="float: left; text-align: center; width: 14em; padding:1em;"> Patient without risk factors </div>| D03=<div style="float: left; text-align: center; width: 14em; padding:1em;"> [[AVR]] </div> | D04=<div style="float: left; text-align: center; width: 14em; padding:1em;"> [[Transcatheter aortic valve implantation|TAVR]] </div>}}
{{Family tree | D01 | | D02 | | D03 | | D04 | | D01= <div style="float: left; text-align: center; width: 14em; padding:1em;"> Yes </div> | D02=<div style="float: left; text-align: center; width: 14em; padding:1em;"> No </div>| D03=<div style="float: left; text-align: center; width: 14em; padding:1em;"> '''Surgical [[AVR]]''' </div> | D04=<div style="float: left; text-align: center; width: 14em; padding:1em;"> '''[[Transcatheter aortic valve implantation|TAVR]]''' </div>}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | }}
{{Family tree | |!| | | |!| | | |!| | | |!| | | }}
{{Family tree | E01 | | E02 | | E03 | | E04 | | E01=<div style="float: left; text-align: left; width: 14em; padding:1em;"> ❑ Give [[warfarin]] to achieve [[INR]] of 3.0 <br> ❑ Give [[aspirin]] 75-100 mg/d <br>''Both long term'' </div> | E02=<div style="float: left; text-align: left; width: 14em; padding:1em;"> ❑ Give [[warfarin]] to achieve [[INR]] of 2.5 <br> ❑ Give [[aspirin]] 75-100 mg/d <br> ''Both long term'' </div>| E03= <div style="float: left; text-align: left; width: 14em; padding:1em;">❑ Give [[warfarin]] to achieve [[INR]] of 2.5 for 3 months <br> ❑ Then give [[aspirin]] 75-100 mg/d long term </div>| E04=<div style="float: left; text-align: left; width: 14em; padding:1em;"> ❑ Give [[clopidogrel]] 75 mg/d <br> ❑ Give [[aspirin]] 75-100 mg/d <br> ''Both for 6 months'' </div> }}
{{Family tree | E01 | | E02 | | E03 | | E04 | | E01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> Administer for long term: <br> ❑ [[Warfarin]] to achieve [[INR]] of 3.0 ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])<br> ''AND'' <br> ❑ [[Aspirin]] 75-100 mg/d ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]])</div> | E02=<div style="float: left; text-align: left; width: 15em; padding:1em;">  Administer for long term: <br> ❑ [[Warfarin]] to achieve [[INR]] of 2.5 ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])<br> ''AND'' <br>❑ [[Aspirin]] 75-100 mg/d ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]])</div>| E03= <div style="float: left; text-align: left; width: 15em; padding:1em;">  Administer <br> ❑ [[Warfarin]] to achieve [[INR]] of 2.5 for 3 months ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: B]])<br> ''AND'' <br>❑ [[Aspirin]] 75-100 mg/d long term ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div>| E04=<div style="float: left; text-align: left; width: 15em; padding:1em;">
 
Administer:
:❑ [[Clopidogrel]] 75 mg/d (first 6 months) ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: C]])<br> ''AND'' <br>❑ [[Aspirin]] 75-100 mg/d (for life) ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div> }}
{{Family tree/end}}
{{Family tree/end}}
<br>
<br>
❑ Either a bioprosthetic or mechanical valve is reasonable in patients between 60 and 70 years of age. ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]).
 
<div style="font-size:80%">†Risk factors for [[thromboembolism]] include [[atrial fibrillation]], [[hypercoagulable conditions]], [[left ventricle]] dysfunction, and previous [[thromboembolism]].</div>


==Do's==
==Do's==
* Administer [[ACE inhibitors]] to control [[hypertension]] among patients with asymptomatic [[aortic stenosis]].<ref name="Chambers2005">{{cite journal|last1=Chambers|first1=J.|title=The left ventricle in aortic stenosis: evidence for the use of ACE inhibitors|journal=Heart|volume=92|issue=3|year=2005|pages=420–423|issn=1355-6037|doi=10.1136/hrt.2005.074112}}</ref>
* Perform a [[TTE|transthoracic echocardiography (TTE)]] after [[aortic valve replacement]] to evaluate the valve hemodynamics ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
* Perform a [[TTE]] when clinical symptoms or signs suggest prosthetic valve dysfunction ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
* Consider [[exercise testing]] in asymptomatic patients with [[aortic stenosis]] to elicit exercise-induced symptoms and abnormal [[blood pressure]] responses ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: B]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
* Consider [[dobutamine]] stress echocardiography to evaluate patients with low-flow/low-gradient AS and LV dysfunction ([[Aortic stenosis stages|Stage D3]]) ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>


❑  Give [[ACE inhibitors]] to control [[hypertension]] in patients with asymptomatic [[aortic stenosis]]. <ref name="Chambers2005">{{cite journal|last1=Chambers|first1=J.|title=The left ventricle in aortic stenosis: evidence for the use of ACE inhibitors|journal=Heart|volume=92|issue=3|year=2005|pages=420–423|issn=1355-6037|doi=10.1136/hrt.2005.074112}}</ref> <br>
* Consider [[aortic balloon valvotomy]] as a bridge to surgery in hemodynamically unstable adult patients with [[aortic stenosis]] among whom [[aortic valve replacement]] cannot be performed because of a high surgical risk or due to the presence of serious comorbid conditions.([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: C]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
❑ Exercise testing in asymptomatic patients with AS may be considered to elicit exercise-induced symptoms and abnormal blood pressure responses ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: B]]). <br>
❑ Dobutamine stress echocardiography is reasonable to evaluate patients with low-flow/low-gradient AS and LV dysfunction ([[Aortic stenosis stages|Stage D3]]) ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]) <br>
❑ Aortic balloon valvotomy might be reasonable as a bridge to surgery in hemodynamically unstable adult patients with AS who are at high risk for [[AVR]] or  cannot be performed because of serious comorbid conditions.([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: C]]). <br>


==Don'ts==
==Don'ts==
Do not perform a [[stress test]] in a symptomatic patient with [[aortic stenosis stages|stage D]] [[aortic stenosis]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]]). <br>
* Do not perform a [[stress test]] in a symptomatic patient with [[aortic stenosis stages|stage D]] [[aortic stenosis]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
Do not give [[statins]] to prevent hemodynamic progression in patients with mild to moderate [[calcific aortic valve disease]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: A]]). <br>
 
❑  [[Transcatheter aortic valve implantation|TAVR]] is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of [[AS]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]])<br>
* Do not administer [[statins]] to prevent hemodynamic progression in patients with mild to moderate [[calcific aortic valve disease]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: A]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
Do not give [[vasodilators]] to patients with severe [[AS]] as they may cause severe [[hypotension]]. <br>
 
[[Endocarditis prophylaxis]] is not indicated in patients with [[AS]]. <ref name="Bonow-2008">{{Cite journal  | last1 = Bonow | first1 = RO. | last2 = Carabello | first2 = BA. | last3 = Chatterjee | first3 = K. | last4 = de Leon | first4 = AC. | last5 = Faxon | first5 = DP. | last6 = Freed | first6 = MD. | last7 = Gaasch | first7 = WH. | last8 = Lytle | first8 = BW. | last9 = Nishimura | first9 = RA. | title = 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal = Circulation | volume = 118 | issue = 15 | pages = e523-661 | month = Oct | year = 2008 | doi = 10.1161/CIRCULATIONAHA.108.190748 | PMID = 18820172 }}</ref>
* Do not perform a [[TAVR|transcatheter aortic valve implantation (TAVR)]] among patients in whom existing comorbidities would preclude the expected benefit from the correction of [[aortic stenosis]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
 
* Do not administer [[vasodilators]] to patients with severe [[aortic stenosis]] because [[vasodilators]] may cause severe [[hypotension]] which can precipitate or exacerbate the symptoms of [[aortic stenosis]].<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
 
* Do not administer [[endocarditis prophylaxis]] among patients with aortic stenosis.<ref name="Bonow-2008">{{Cite journal  | last1 = Bonow | first1 = RO. | last2 = Carabello | first2 = BA. | last3 = Chatterjee | first3 = K. | last4 = de Leon | first4 = AC. | last5 = Faxon | first5 = DP. | last6 = Freed | first6 = MD. | last7 = Gaasch | first7 = WH. | last8 = Lytle | first8 = BW. | last9 = Nishimura | first9 = RA. | title = 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal = Circulation | volume = 118 | issue = 15 | pages = e523-661 | month = Oct | year = 2008 | doi = 10.1161/CIRCULATIONAHA.108.190748 | PMID = 18820172 }}</ref>


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Latest revision as of 23:21, 14 March 2016

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]; Rim Halaby, M.D. [3]

Aortic Stenosis Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
General Approach
Choice of Intervention
Type of Valve and Discharge Anticoagulation Therapy
Do's
Don'ts

Overview

Aortic stenosis is the progressive narrowing of the diameter of the aortic valve (normal valve area is 3 - 4 cm²). The symptoms are caused by a decrease in the stroke volume which reduces blood flow to peripheral tissues. The most common etiology of aortic stenosis is calcific aortic valve disease. The management of aortic stenosis depends on the stage of the disease which is determined by whether the patient is symptomatic or asymptomatic, the area of the valve, and the hemodynamic consequences of the stenosis.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Aortic stenosis is a progressive disease and does not have a life threatening cause.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[1]
Boxes in the red signify that an urgent management is needed.

Abbreviations: AVR: Aortic valve replacement; CK-MB: Creatine kinase myocardial type; ECG: Electrocardiogram; NSTEMI: Non ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; TTE: Transthoracic echocardiography

 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of aortic stenosis

Systolic ejection murmur
❑ Crescendo-decrescendo
❑ Associated with an ejection click
❑ Best heard at the upper right sternal border
❑ Bilateral radiation to the carotid arteries
❑ Increases with squatting and expiration
❑ Decreases with valsalva maneuver

Pulsus parvus et tardus (a weak and slow upstroke of the carotid waveform is an excellent indicator of aortic stenosis severity)

Narrow pulse pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings require urgent management?
Tachycardia
Hypotension
Severe dyspnea
Loss of consciousness
Chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to the
complete diagnostic approach below
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a condition that exacerbates AS
 
 
 
 
 
The patient has a decompensated AS causing complications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Suspect if there are palpitations
❑ Order an ECG immediately looking for
❑ Irregularly irregular rhythm, and
❑ Absent P waves
 

❑ Suspect if there is severe chest pain
❑ Order an ECG immediately

❑ Order troponin and CK-MB

 

❑ Suspect if there is loss of consciousness of:
❑ Short duration
❑ Rapid onset
❑ Complete spontaneous recovery
 

❑ Suspect if there are:
❑ Severe dyspnea
❑ Signs of volume overload
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat the complications of aortic stenosis that lead to decompensation
❑ Order a TTE to evaluate the severity of the aortic stenosis
❑ Do not give nitrates (could cause severe hypotension)
❑ Monitor vital signs continuously
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient improve with medical therapy?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with urgent AVR
 
 



Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[1]

Abbreviations: AS: Aortic stenosis; AF: Atrial fibrillation; AVR: Aortic valve replacement; CXR: Chest X-ray; ECG: Electrocardiogram; LBBB: Left bundle branch block; LVH: Left ventricle hypertrophy; TAVR: Transcatheter aortic valve replacement; TTE: Transthoracic echocardiography; VHD: Valvular heart disease

 
 
 
 
Characterize the symptoms:

Chest pain, angina-type pain (Left untreated, the average survival is 5 years after the onset of angina in the patient with AS)

❑ The pain is crushing, squeezing, pressure or tightness in nature
❑ The pain increases with exercise, relieved with rest
❑ Pain under the chest bone, it may move to other areas

Syncope (Left untreated, the average survival is 3 years after the onset of syncope in the patient with AS)
❑ Symptoms suggestive of congestive heart failure (Left untreated, the average survival is 1 years after the onset of heart failure in the patient with AS)

Dyspnea on exertion
Fatigue
Orthopnea
Paroxysmal nocturnal dyspnea
Pulmonary edema
Pulmonary hypertension that can lead to:
Right ventricular failure
Hepatomegaly
Atrial fibrillation
Peripheral edema
Tricuspid regurgitation

Palpitations

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about past medical history:
Cardiovascular disease
Hypertension
Bicuspid aortic valve
Rheumatic fever
Pulmonary disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
Heart rate

❑ Normal rhythm and rate (in most cases)
❑ Irregularly irregular rhythm (suggestive of AF in late stage disease)

Blood pressure

Narrow pulse pressure (<25 mmHg)
❑ Mild hypertension in moderate stenosis
Hypotension in severe stenosis

❑ Respiratory rate

❑ Normal in most cases
Tachypnea (suggestive of HF)


Cardiovascular examination
Cardiac palpation

Apical impulse (suggestive of LVH)
Palpable thrill

❑ Pulses

Pulsus parvus et tardus
Pulsus bisferiens (suggestive of mixed aortic stenosis and regurgitation)

Cardiac auscultation

Murmur
❑ Crescendo-decrescendo systolic ejection murmur with ejection click
❑ Best heard at the upper right sternal border
❑ Bilateral radiation to the carotid arteries
❑ Murmur increases with squatting and expiration
❑ Murmur decreases with valsalva maneuver

Click on the video below to listen to an aortic stenosis murmur. {{#ev:youtube|MJg257pyt4I|200}}

Heart sounds
❑ Normal S1
Paradoxical splitting of S2 (in severe disease)
S3 (suggestive of LVH)


Respiratory examination
Rales (suggestive of congestive heart failure)


Extremities
Peripheral edema (suggestive of congestive heart failure)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:

TTE (most important evaluation test) (Class I; Level of Evidence: B)

Assess the following:
❑ Valve morphology
❑ Pressure gradient
Aortic valve area
Ejection fraction
Left ventricle wall thickness and motility

ECG (shows non-specific findings):

LVH
Left atrium enlargement
LBBB
AF (in late disease)

Chest X-ray:

Cardiomegaly
Valve calcification
❑ Dilatation of ascending aorta
Pulmonary congestion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify aortic stenosis based on the following findings on TTE:
❑ Valve area (cm²)
❑ Transvalvular pressure gradient (mmHg)
❑ Aortic Vmax (m/s)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No stenosis

❑ Valve area 2.5-3.5 cm²
❑ No pressure gradient across the valve
❑ Aortic Vmax <2 m/s
 
Mild stenosis

❑ Valve area 1.5-2.5 cm²
❑ Pressure gradient ≤ 25 mmHg
❑ Aortic Vmax 2.0-2.9 m/s
 
Moderate stenosis

❑ Valve area 1.0-1.5 cm²
❑ Pressure gradient 25-40 mmHg
❑ Aortic Vmax 3.0-3.9 m/s
 
Severe stenosis

❑ Valve area ≤ 1.0 cm²
❑ Pressure gradient ≥ 40 mmHg
(except for stages D2 and D3, low flow low gradient)
❑ Aortic Vmax ≥ 4 m/s
 
 
 
 

Treatment

Indications for Aortic Valve Replacement

Shown below is an algorithm depicting the indications for aortic valve replacement (AVR). If the patient does not meet any of the decision pathways in the algorithm, regular monitoring is recommended and AVR is not indicated.[1]

Abbreviations: AVR: Aortic valve replacement; LVEF: Left ventricular ejection fraction; ΔPmean: mean pressure gradient; Vmax: maximum velocity

 
 
 
 
 
 
 
 
 
 
 
Abnormal aortic valve
AND
Reduction in systolic opening
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe aortic stenosis:
Vmax≥4m/s
AND
ΔPmean≥40 mmHg
 
 
 
 
 
 
 
 
 
 
Vmax3-3.9 m/s
AND
ΔPmean20-39 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
(Stage D1)
 
 
 
 
 
No
(Stage C)
 
 
 
Yes
 
 
 
No
(Stage B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LVEF <50%
(Stage C2)
 
 
 
 
Is LVEF <50%?
 
 
 
The patient is undergoing
another cardiac surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient is undergoing
another cardiac surgery
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vmax≥5m/s
AND
ΔPmean≥60 mmHg
(Very severe stage C1)
AND
Low surgical risk
 
 
Dobutamine stress echocardiography:
Aortic valve area ≤1 cm2
AND
Vmax≥4 ms
(Stage D2)
 
Aortic valve area ≤1 cm2
AND
LVEF ≥50%
(Stage D3)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal exercise treadmill test
 
 
 
 
 
 
 
The symptoms are likely
the result of the aortic stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ΔVmax>0.3 m/s/y
AND
Low surgical risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AVR (Class I)
 
AVR (Class IIa)
 
AVR (Class IIb)
 
AVR (Class IIa)
 
AVR (Class IIa)
 
AVR (Class IIa)

Choice of Intervention

Shown below is a table summarizing the choice of aortic valve replacement among patients with aortic stenosis based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease [1]

Choice of AVR Indications
Surgical AVR - Low or intermediate surgical risk

(Class I; Level of Evidence: A)

Tansthoracic aortic valve replacement (TAVR) - Prohibitive surgical risk and a predicted post-TAVR survival >12 month (Class I; Level of Evidence: B)

- High surgical risk (Class IIa; Level of Evidence: B)

Evaluation of Surgical and Interventional Cardiac Risk

Shown below is a table to assess the surgical and interventional risk which combines the Society of Thoracic Surgeons (STS) risk estimate, frailty, major organ system dysfunction and procedure-specific impediments.[1]

STC Predicted Risk of Mortality Score[2] Frailty* Major organ system compromised without postoperative improvement Specific procedural impediment**
Low risk
(Must meet ALL criteria in this row)
<4% None None None
Intermediate risk
(Must meet ANY criteria in this row)
4% to 8% 1 index (mild) 1 organ system Possible
High risk
(Must meet ANY criteria in this row)
>8% ≥2 indices (moderate to severe) No more than 2 organ systems Possible
Prohibitive risk
(Must meet ANY criteria in this row)
>50% of predicted risk of death or major morbidity at 1 year >50% of predicted risk of death or major morbidity at 1 year ≥3 organ systems Severe

*Seven frailty indices: Katz Activites of Daily Living (self-sufficient in feeding, bathing, dressing, transferring, toileting, and urinary continence) and self-sufficient in deambulation (no walking aid or assist required or 5-meter walk in <6 s).
**Examples of specific procedural impediment: tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall or radiation damage.

Type of Valve and Discharge Anticoagulation Therapy

Abbreviations: AVR: Aortic valve replacement; INR: International normalized ratio; TAVR Tansthoracic aortic valve replacement

 
 
 
 
 
 
Determine:
Age
Contraindications for anticoagulation
❑ Major bleeding diathesis or coagulopathy
❑ Uncontrolled severe hypertension (systolic blood pressure >200 mmHg)
❑ Recent head trauma
❑ Platelet count < 100 000
Pregnancy
❑ Hypersensitivity to warfarin
Hemorrhagic stroke
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Patients ≤ 60 years old
AND
❑ No contraindication for anticoagulation (Class IIa; Level of Evidence: B)
 
❑ Patients 60 - 70 years old
AND
❑ No contraindication for anticoagulation
 
❑ Patients ≥ 70 years old (Class IIa; Level of Evidence: B)
OR
❑ Patients at any age AND contraindications for anticoagulation therapy (Class I; Level of Evidence: C)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bioprosthesic
OR
Mechanical prosthesis (Class IIa; Level of Evidence: B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mechanical prosthesis
Avoid the use of direct thrombin inhibitors or anti-Xa agents in patients with mechanical prosthesis (Class III; Level of Evidence: B)
 
 
 
 
 
Bioprosthesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have risk factors for thromboembolism†?
 
 
 
 
 
Surgical AVR
OR
TAVR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
Surgical AVR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer for long term:
Warfarin to achieve INR of 3.0 (Class I; Level of Evidence: B)
AND
Aspirin 75-100 mg/d (Class I; Level of Evidence: A)
 
Administer for long term:
Warfarin to achieve INR of 2.5 (Class I; Level of Evidence: B)
AND
Aspirin 75-100 mg/d (Class I; Level of Evidence: A)
 
Administer
Warfarin to achieve INR of 2.5 for 3 months (Class IIb; Level of Evidence: B)
AND
Aspirin 75-100 mg/d long term (Class IIa; Level of Evidence: B)
 

Administer:

Clopidogrel 75 mg/d (first 6 months) (Class IIb; Level of Evidence: C)
AND
Aspirin 75-100 mg/d (for life) (Class IIa; Level of Evidence: B)
 


†Risk factors for thromboembolism include atrial fibrillation, hypercoagulable conditions, left ventricle dysfunction, and previous thromboembolism.

Do's

Don'ts

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.
  2. "Online STS Risk Calculator". Retrieved 7 March 2014.
  3. Chambers, J. (2005). "The left ventricle in aortic stenosis: evidence for the use of ACE inhibitors". Heart. 92 (3): 420–423. doi:10.1136/hrt.2005.074112. ISSN 1355-6037.
  4. Bonow, RO.; Carabello, BA.; Chatterjee, K.; de Leon, AC.; Faxon, DP.; Freed, MD.; Gaasch, WH.; Lytle, BW.; Nishimura, RA. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)


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