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{{Aortic stenosis surgery}}
{{Aortic stenosis surgery}}


{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{USAMA}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{USAMA}}
{{SK}} As; Aortic stenosis; AVR; Aortic valve replacement; LVEF; Left ventricular ejection fraction; LV; Left ventricle


==Overview==
==Overview==
Aortic stenosis requires aortic valve replacement if medical management does not successfully control symptoms.
In symptomatic [[patients]] with severe high-gradient [[AS]] (Stage D1), [[AVR]] has beneficial effect on [[survival]], [[symptoms]], and [[LV systolic function]]. In asymptomatic [[patients]] with [[severe AS]] and normal [[LV]] [[systolic function]], the risk of [[sudden death]] (<1% per year) is low. In [[patients]] with a low [[LVEF]] and severe [[AS]], [[survival]] is better with [[AVR]] than [[medical therapy]].
According to a prospective, single-center, nonrandomized study of 25 patients, percutaneous implantation of an aortic valve prosthesis in high risk patients with aortic stenosis results in marked hemodynamic and clinical improvement when successfully completed.<ref>{{cite journal |author=Grube E, Laborde JC, Gerckens U, ''et al'' |title=Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study |journal=Circulation |volume=114 |issue=15 |pages=1616-24 |year=2006 |pmid=17015786 |doi=10.1161/CIRCULATIONAHA.106.639450}}</ref>


==Indications==
==Indications==
In symptomatic patients with severe high-gradient AS (Stage D1), ample evidence demonstrates the beneficial effects of AVR on survival, symptoms, and LV systolic function.35,41–46 The most common initial symptom of AS is exertional dyspnea or decreased exercise tolerance. Clinical vigilance is needed to recognize these early symptoms and proceed promptly to AVR. More severe “classical” symptoms of AS, including HF, syncope, or angina, can be avoided by appropriate treatment at the onset of even mild symptoms. Outcomes after surgical or transcatheter AVR are excellent in patients who do not have a high procedural risk.41,43–45 Surgical series demonstrate improved symptoms after AVR, and most patients have an improvement in exercise tolerance, as documented in studies with pre- and post-AVR exercise stress testing.41,43–46 Historical observation studies on outcomes in symptomatic patients with severe AS have been confirmed in RCTs comparing TAVI with palliative care in patients with a prohibitive surgical risk. The choice of surgical versus transcatheter AVR for patients with an indication for AVR is discussed in Section 3.2.4.1–3,5,6,12–16,35,42,47–55
* In [[symptomatic]] [[patients]] with severe [[high-gradient]] [[AS]] (Stage D1), [[AVR]] has beneficial effects on [[survival]], [[symptoms]], and [[LV systolic function]].
2.
* The most common initial [[symptom]] of [[ AS]] is [[exertional dyspnea]] or decreased [[exercise tolerance]].
In asymptomatic patients with severe AS and normal LV systolic function, the survival rate during the asymptomatic phase is similar to that of age-matched controls, with a low risk of sudden death (<1% per year) when patients are followed prospectively and when patients promptly report symptom onset. However, in patients with a low LVEF and severe AS, survival is better in those who undergo AVR than in those treated medically. The depressed LVEF in many patients is caused by excessive afterload (afterload mismatch), and LV function improves after AVR in such patients. If LV dysfunction is not caused by afterload mismatch, survival is still improved, likely because of the reduced afterload with AVR, but improvement in LV function and resolution of symptoms might not be complete after AVR.17,23,24,56–62
* More severe classical symptoms of [[AS]], including [[HF]], [[syncope]], or [[angina]], can be avoided by appropriate treatment at the onset of even mild symptoms.
3.
* [[Outcomes]] after [[surgical]] or [[transcatheter]] [[AVR]] are excellent.
Prospective clinical studies demonstrate that disease progression occurs in nearly all patients with severe asymptomatic AS. Symptom onset within 2 to 5 years is likely when aortic velocity is ≥4.0 m/s or mean pressure gradient is ≥40 mm Hg. The additive risk of AVR at the time of other cardiac surgery is less than the risk of reoperation within 5 years.12–16,63–65
* Improvement in [[exercise tolerance]] has been shown by [[exercise test]] after [[AVR]].
4.
*In [[asymptomatic]] [[patients]] with severe [[AS]] and normal [[LV systolic function]], the risk of [[sudden death]] is low (<1% per year). However, in [[patients]] with a low [[LVEF]] and severe [[AS]], [[survival]] is better in those who undergo [[AVR]] than in those treated medically.<ref name="pmid10965007">{{cite journal |vauthors=Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M, Maurer G, Baumgartner H |title=Predictors of outcome in severe, asymptomatic aortic stenosis |journal=N Engl J Med |volume=343 |issue=9 |pages=611–7 |date=August 2000 |pmid=10965007 |doi=10.1056/NEJM200008313430903 |url=}}</ref>
Mean pressure gradient is a strong predictor of outcome after AVR, with better outcomes seen in patients with higher gradients. Outcomes are poor with severe low-gradient AS but are still better with AVR than with medical therapy in those with a low LVEF, particularly when contractile reserve is present. The document “Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice” defines severe AS on dobutamine stress testing as a maximum velocity >4.0 m/s with a valve area ≤1.0 cm2 at any point during the test protocol, with a maximum dobutamine dose of 20 mcg/kg per minute.66 The recommendation for AVR in these patients is based on outcome data in several prospective nonrandomized studies. LVEF typically increases by 10 LVEF units and may return to normal if afterload mismatch was the cause of LV systolic dysfunction. If dobutamine stress testing indicates moderate, not severe AS, GDMT for HF can be continued without AVR. Patients without contractile reserve may also benefit from AVR, but decisions in these high-risk patients must be individualized because outcomes are poor with either surgical or medical therapy. The role of TAVI in these patients is currently under investigation.17,22–24,59,60,67
* [[Disease]] progression occurs in nearly all [[patients]] with severe asymptomatic [[AS]]. Initiation of [[symptoms]]  within 2 to 5 years is likely when [[aortic]] velocity is ≥4.0 m/s or [[mean pressure gradient]] is ≥40 mm Hg.
5.
A subset of patients with severe AS presents with symptoms and with a low velocity, low gradient, and low stroke volume index, despite a normal LVEF. Low-flow, low-gradient severe AS with preserved LVEF should be considered in patients with a severely calcified aortic valve, an aortic velocity <4.0 m/s (mean pressure gradient <40 mm Hg), and a valve area ≤1.0 cm2 when stroke volume index is <35 mL/m2. Typically, the LV is small, with thick walls, diastolic dysfunction, and a normal LVEF (≥50%). The first diagnostic step is to ensure that data were recorded and measured correctly. If hypertension is present, blood pressure is controlled before reevaluation of AS severity. Next, valve area is indexed to body size because an apparent small valve area may be only moderate AS in a small patient; an aortic valve area index ≤0.6 cm2/m2 suggests severe AS. Transaortic stroke volume is calculated by Doppler or 2D imaging. Measurement of a CT calcium score often is helpful. Evaluation for other potential causes of symptoms ensures that symptoms are most likely attributable to valve obstruction. Although the survival rate after TAVI is lower in patients with low-flow severe AS than in patients with normal-flow severe AS, AVR appears beneficial, with an increase in stroke volume and improved survival as compared with medical therapy.18,25–27,54,68–76
*Mean [[pressure gradient]] is a strong predictor of outcome after [[AVR]], with better outcomes seen in [[patients]] with higher [[gradients]].
6.
* [[Outcomes]] are poor with severe [[low-gradient]] [[AS]] but are still better with [[AVR]] than with medical therapy in those with a low [[LVEF]], especially in the presence of [[contractile reserve]].
Exercise testing may be helpful in clarifying symptom status in patients with severe AS. When symptoms are provoked by exercise testing, the patient is considered symptomatic and meets a COR 1 recommendation for AVR; symptoms are symptoms, whether reported spontaneously by the patient or provoked on exercise testing. The rate of symptom onset within 1 to 2 years is high (about 60% to 80%) in patients without overt symptoms who demonstrate 1) a fall of ≥10 mm Hg in systolic blood pressure from baseline to peak exercise or 2) a significant decrease in exercise tolerance as compared with age and sex normal standards. Management of patients with a lack of appropriate rise in BP with exercise is less clear. Decisions about elective AVR in these patients include consideration of surgical risk, patient preferences, and clinical factors, such as age and comorbid conditions.13,28,77–82
*  Severe [[AS]] on [[dobutamine stress testing]]  is defined when a maximum [[velocity]] >4.0 m/s with a [[valve area]] ≤1.0 cm2 at any point during the test protocol, with a maximum [[dobutamine]] dose of 20 mcg/kg per minute.
7.
* [[Outcome]] in [[patients]] without contractil reserve is poor with either [[surgical]] or [[medical therapy]].
In patients with very severe AS and an aortic velocity ≥5.0 m/s or mean pressure gradient ≥60 mm Hg, the rate of symptom onset is approximately 50% at 2 years. On multivariable analysis of a large cohort of adults with asymptomatic AS (>500 patients), an aortic velocity ≥5 m/s was associated with a >6-fold increased risk of cardiovascular mortality (hazard ratio [HR]: 6.31; 95% CI: 2.61–15.9).33 A randomized trial of SAVR versus continued surveillance showed a significant survival benefit to early surgery in patients with aortic velocity ≥4.5 m/s.31 In patients very severe asymptomatic AS and low surgical risk, a decision to proceed with AVR or continue watchful waiting takes into account patient age, avoidance of patient–prosthesis mismatch, anticoagulation issues, and patient preferences.31–33,39
* In [[patients]] undergone [[AVR]], [[LVEF]] typically increases by 10 [[LVEF]] units and may return to normal if [[afterload]] mismatch was the cause of [[LV systolic dysfunction]].
8.
* Low-flow, low-gradient severe [[AS]] with preserved [[LVEF]] should be considered in [[patients]] with a severely calcified [[aortic valve]], an [[aortic velocity]] <4.0 m/s (mean [[pressure gradient]] <40 mm Hg), and a [[valve area]] ≤1.0 cm2, [[stroke volume index]] <35 mL/m2, presence of small [[LV cavity]] with thick walls, [[diastolic dysfunction]], and a normal [[LVEF]] (≥50%).<ref name="pmid19442886">{{cite journal |vauthors=Tribouilloy C, Lévy F, Rusinaru D, Guéret P, Petit-Eisenmann H, Baleynaud S, Jobic Y, Adams C, Lelong B, Pasquet A, Chauvel C, Metz D, Quéré JP, Monin JL |title=Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography |journal=J Am Coll Cardiol |volume=53 |issue=20 |pages=1865–73 |date=May 2009 |pmid=19442886 |doi=10.1016/j.jacc.2009.02.026 |url=}}</ref>
An elevated serum BNP level is a marker of subclinical HF and LV decompensation. In a cohort of 387 asymptomatic adults with severe AS, elevated BNP levels were associated with an increased 5-year risk of AS-related events, with a hazard ratio for a BNP level >300 pg/mL (3 times normal) of 7.38 (CI: 3.21 to 16.9).32 Serum BNP levels also are predictive of symptom onset during follow-up and persistent symptoms after AVR.36
* If [[hypertension]] is present, [[blood pressure]]  should is controlled before reevaluation of [[AS]] severity.
9.
* [[Valve area]] is indexed to [[body]] size because an apparent small [[valve area]] may be only moderate [[AS]] in a small [[patient]].
Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptomatic patients with AS once the aortic velocity reaches ≥2 m/s. Although the average rate of hemodynamic progression for calcific stenosis of a trileaflet valve is an increase in aortic velocity of about 0.3 m/s per year, an increase in mean gradient of 7 to 8 mm Hg per year, and a decrease in valve area of 0.15 cm2 per year, there is marked variability between patients in disease progression. Predictors of rapid disease progression include older age, more severe valve calcification, and a faster rate of hemodynamic progression on serial studies. In patients with an aortic velocity >4 m/s in addition to predictors of rapid disease progression, symptom onset is likely in the near future, so there is less benefit to waiting for symptom onset. Thus, elective AVR may be considered if the surgical risk is low and after consideration of other clinical factors and patient preferences.
* An [[aortic valve area]] index ≤0.6 cm2/m2 suggests severe [[AS]].
10.
* [[Transaortic]] [[stroke volume]] is calculated by [[Doppler]] or [[2D]] imaging.
In adults with initially asymptomatic severe AS, the rate of sudden death is low (<1% per year). However, an aortic velocity ≥5 m/s or an LVEF <60% each is associated with higher all-cause and cardiovascular mortality rates in the absence of AVR.31 A multivariate analysis of predictors of death in a large cohort (>500 patients) showed a >4-fold higher risk of cardiovascular death for those with an LVEF <60% than for those with a higher LVEF (HR: 4.47; 95% CI: 2.06 to 9.70).33 A progressive decrease in LVEF is most likely in those with an LVEF <60% before AS becomes severe.8,9,11 Evaluation for other causes of a decline in LVEF is appropriate, particularly when AS is not yet severe, but a progressive decline in LV systolic function is of concern and should prompt more frequent evaluation; and consideration of AVR when repeat studies show a progressive decline in LVEF without other cause with a lack of response to medical therapy. The presence of at least 3 serial imaging studies showing a consistent decline in LVEF ensures that the changes seen are not simply attributable to recording, measurement, or physiological variability.8–11
* [[Exercise testing]] may be helpful in clarifying symptom status in [[patients]] with severe [[AS]] including a fall of ≥10 mm Hg in [[systolic blood pressure]] from baseline to peak [[exercise]] or a significant decrease in [[exercise]] tolerance as compared with [[age]] and [[sex]] normal standards.
11.
* In [[patients]] with very severe [[AS]] and an [[aortic velocity]] ≥5.0 m/s or mean [[pressure gradient]] ≥60 mm Hg, the rate of [[symptom]] onset is approximately 50% at 2 years. <ref name="pmid20026771">{{cite journal |vauthors=Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G |title=Natural history of very severe aortic stenosis |journal=Circulation |volume=121 |issue=1 |pages=151–6 |date=January 2010 |pmid=20026771 |doi=10.1161/CIRCULATIONAHA.109.894170 |url=}}</ref> *Early [[surgery]] in [[patients]] with [[aortic velocity]] ≥4.5 m/s showed significant [[survival]] benefit.
Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptomatic patients with AS. The survival rate during the asymptomatic phase is similar to age-matched controls, with a low risk of sudden death (<1% per year) when patients are followed prospectively and when patients promptly report symptom onset. The rate of symptom onset is strongly dependent on the severity of AS, with an event-free survival rate of about 75% to 80% at 2 years in those with a jet velocity <3.0 m/s, compared with only 30% to 50% in those with a jet velocity ≥4.0 m/s. Patients with asymptomatic AS require periodic monitoring for development of symptoms and progressive disease (Section 3.1). In patients with moderate calcific AS undergoing cardiac surgery for other indications, the risk of progressive VHD is balanced against the risk of repeat surgery or TAVI (Sections 4.3.3 and 10). This decision must be individualized on the basis of the specific operative risk in each patient, clinical factors such as age and comorbid conditions, valve durability, and patient preferences.
* An elevated [[serum]] [[BNP]] level is a marker of subclinical [[HF]] and [[LV ]] decompensation in [[severe]] [[AS]].<ref name="pmid15117847">{{cite journal |vauthors=Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, Binder T, Pacher R, Maurer G, Baumgartner H |title=Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis |journal=Circulation |volume=109 |issue=19 |pages=2302–8 |date=May 2004 |pmid=15117847 |doi=10.1161/01.CIR.0000126825.50903.18 |url=}}</ref>
 
* In [[asymptomatic]] [[patients]] with [[AS]] with the [[aortic]] velocity reaches ≥2 m/s, [[hemodynamic]] progression leading to [[symptom ]]. <ref name="pmid26477634">{{cite journal |vauthors=Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Murakami T, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Sakata R, Kimura T |title=Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis |journal=J Am Coll Cardiol |volume=66 |issue=25 |pages=2827–2838 |date=December 2015 |pmid=26477634 |doi=10.1016/j.jacc.2015.10.001 |url=}}</ref>
 
* [[Hemodynamic]] progression occurs when [[aortic]] velocity increases about 0.3 m/s per year, an increase in the [[mean gradient]] of 7 to 8 mm Hg per year, and a decrease in [[valve area]] of 0.15 cm2 per year.
* Predictors of [[rapid]] [[disease]] progression include [[older age]], more severe [[valve calcification]], and a faster rate of [[hemodynamic]] progression in serial studies.
* Elective [[AVR]] may be considered In [[patients]] with an [[aortic]] [[velocity]] >4 m/s, and the presence of predictors of rapid disease progression.<ref name="pmid31733181">{{cite journal |vauthors=Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, Yun SC, Hong GR, Song JM, Chung CH, Song JK, Lee JW, Park SW |title=Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis |journal=N Engl J Med |volume=382 |issue=2 |pages=111–119 |date=January 2020 |pmid=31733181 |doi=10.1056/NEJMoa1912846 |url=}}</ref>
* In [[adults]] with initially asymptomatic severe [[AS]], the rate of [[sudden death]] is low (<1% per year). However, an [[aortic velocity]] ≥5 m/s or an [[LVEF]] <60% is associated with higher all-cause and [[cardiovascular]] [[mortality rates]] in the absence of [[AVR]].
* A progressive decrease in [[LVEF]] is most likely in those with an [[LVEF]] <60% before [[AS]] becomes severe.<ref name="pmid29289632">{{cite journal |vauthors=Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kadota K, Izumi C, Nakatsuma K, Sasa T, Watanabe H, Kuwabara Y, Makiyama T, Ono K, Shizuta S, Kato T, Saito N, Minatoya K, Kimura T |title=Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis |journal=JACC Cardiovasc Interv |volume=11 |issue=2 |pages=145–157 |date=January 2018 |pmid=29289632 |doi=10.1016/j.jcin.2017.08.036 |url=}}</ref>
* [[Hemodynamic]] progression eventually leading to onset of [[symptom]] occurs in nearly all asymptomatic [[patients]] with [[AS]].
. The rate of [[symptom]] onset is strongly dependent on the severity of [[AS]].
* [[Patients]] with asymptomatic [[AS]] require periodic monitoring for the development of [[symptoms]] and progressive [[disease]].


== 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines<ref name="pmid30121240">{{cite journal| author=Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM | display-authors=etal| title=2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2019 | volume= 73 | issue= 12 | pages= 1494-1563 | pmid=30121240 | doi=10.1016/j.jacc.2018.08.1028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30121240  }}</ref> ==


=== Therapeutic Recommendations for Subaortic Stenosis ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" | [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.''' Surgical intervention is recommended for adults with subAS, a maximum gradient 50 mm Hg or more and symptoms attributable to the subAS.''(Level of Evidence: C-EO)''
|-
| bgcolor="LightGreen" | '''2.'''Surgical intervention is recommended for adults with subAS and less than 50 mm Hg maximum gradient and HF or ischemic symptoms, and/or LV systolic dysfunction attributable to subAS.
''(Level of Evidence: C-LD)''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |'''1.'''To prevent the progression of AR, surgical intervention may be considered for asymptomatic adults with subAS and at least mild AR and a maximum gradient of 50 mm Hg or more.
''(Level of Evidence: C-LD)''
|}




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❑  [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
❑  [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]], [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2)<br>
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2)<br>
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve<br>
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve<br>
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</span>
 
<br>
<br>


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*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of  Normal flow by [[pulsed Doppler echocardiography]] is :
* Normal flow by [[pulsed Doppler echocardiography]] is defined as:
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as  [[AVA]] >1.0 cm2 with increased [[flow]].
*Pseudo-severe [[aortic stenosis]] is defined when [[AVA]] >1.0 cm2 with increased [[flow]].<ref name="pmid22733832">{{cite journal |vauthors=Fougères E, Tribouilloy C, Monchi M, Petit-Eisenmann H, Baleynaud S, Pasquet A, Chauvel C, Metz D, Adams C, Rusinaru D, Guéret P, Monin JL |title=Outcomes of pseudo-severe aortic stenosis under conservative treatment |journal=Eur Heart J |volume=33 |issue=19 |pages=2426–33 |date=October 2012 |pmid=22733832 |doi=10.1093/eurheartj/ehs176 |url=}}</ref>
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:  
*[[CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of [[AS]] severity:  
*:men >3000, [[ women]]>1600  
*: High likely: [[men]] >3000, [[ women]]>1600  
*:Likely: [[men]] >2000, [[women]] >1200
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800
*:Unlikely: [[men]] <1600, [[women]] <800
 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shown below is an algorithm summarizing the management of symptomatic and asymptomatic patients with aortic stenosis and the indications for [[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="pmid9870202">{{cite journal| author=Bonow RO, Carabello B, de Leon AC, Edmunds LH, Fedderly BJ, Freed MD et al.| title=ACC/AHA Guidelines 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 (Committee on Management of Patients With Valvular Heart Disease). | journal=J Heart Valve Dis | year= 1998 | volume= 7 | issue= 6 | pages= 672-707 | pmid=9870202 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9870202  }} </ref><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>
 
{{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}}
 
Shown below is an algorithm summarizing the approach to patients with low flow, low gradient aortic stenosis.<ref name="pmid23062546">{{cite journal| author=Pibarot P, Dumesnil JG| title=Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 19 | pages= 1845-53 | pmid=23062546 | doi=10.1016/j.jacc.2012.06.051 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23062546  }} </ref>
 
<span style="font-size:85%">'''Abbreviations:''' '''AVR:''' [[Aortic valve replacement]]; '''EOA:''' Effective orifice area; '''ΔP<sub>mean</sub>:''' mean pressure gradient</span>
 
{{familytree/start}}
{{familytree | | | A01 | | | | | | A01= '''Ultrasound evaluation of aortic stenosis'''<br> Effective orifice area (EOA)≤ 1 cm<sup>2</sup><br> Pressure gradient (ΔP)<40 mmHg}}
{{familytree | | | |!| | | | | | | }}
{{familytree | | | B01 | | | | | B01= '''Low grade low flow aortic stenosis'''}}
{{familytree | |,|-|^|-|.| | | | | }}
{{familytree | C01 | | C02 | | | C01= Normal left ventricular ejection fraction| C02= Left ventricular ejection fraction≤ 40-50%<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>}}
{{familytree | |!| | | |!| | | | }}
{{familytree | C03 | | |!| | | | C03= '''No specific recommendations:''' <br>'''- Surgical [[aortic valve replacement|AVR]], or''' <br>'''- Transcather AVR, or''' <br> '''- Medical treatment'''}}
{{familytree | | | | | D01 | | | D01= '''[[Dobutamine stress test]]'''}}
{{familytree | | | |,|-|^|-|.| | | }}
{{familytree | | | E01 | | E02 | E01= Increase in [[stroke volume]] by ≥ 20%| E02= Increase in [[stroke volume]] by <20%}}
{{familytree | | | |!| | | |!| | | }}
{{familytree | | | F01 | | F02 | F01= Presence of left ventricular flow reserve| F02= Absence of left ventricular flow reserve}}
{{familytree | |,|-|^|.| |,|^|-|.| }}
{{familytree | G01 | | G02 | | G03 | G01= ΔP≥40 <br> EOA<1-1.2| G02= ΔP<40 <br> EOA≥1-1.2| G03= EOA<1-1.2}}
{{familytree | |!| | | |!| | | |!| | }}
{{familytree | H01 | | H02 | | H03 |H01= '''True severe aortic stenosis'''| H02= '''Pseudo-severe aortic stenosis'''| H03= '''True severe aortic stenosis'''}}
{{familytree | |!| | | |!| | | |!| | }}
{{familytree | I01 | | I02 | | I03 | I01= '''Surgical AVR''' <br>'''with/without [[CABG]]'''| I02= '''Medical treatment'''<br> '''Close follow up'''| I03= '''Transcather AVR'''}}
{{familytree/end}}
<br>
 
Aortic valve replacement is indicated in the following situations:
*If the patient has symptoms due to aortic stenosis, such as [[angina]], [[dizziness]], [[syncope]], [[dyspnea]] or [[heart failure]] symptoms <ref name="pmid15967862">{{cite journal| author=Freeman RV, Otto CM| title=Spectrum of calcific aortic valve disease: pathogenesis, disease progression, and treatment strategies. | journal=Circulation | year= 2005 | volume= 111 | issue= 24 | pages= 3316-26 | pmid=15967862 | doi=10.1161/CIRCULATIONAHA.104.486738 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15967862  }} </ref>. Average survival after the onset of these symptoms is around two to three years <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| 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 | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172  }} </ref>. With the presence of symptoms; the patient may be at risk for sudden death <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| 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 | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172  }} </ref>.
*Severe aortic stenosis (valve area < 1.0 cm<sup>2</sup>, or the aortic jet velocity is over 4.0 m/sec and the mean transvalvular gradient exceeds 40 mm Hg) if the patient has symptoms, left ventricular dysfunction ([[ejection fraction]] < 50%) or undergoing [[coronary artery bypass grafting]]. Valve replacement should not be performed for isolated severe AS in asymptomatic patients.
*Usually performed in patients with moderate AS with symptoms to improve symptoms and prolong life expectancy, or if the patient undergoing [[coronary artery bypass grafting]] or aortic root reconstruction surgery.
 
If there are no contraindications to [[anticoagulants]], mechanical prostheses are preferred in patients < 65 years of age. If the patient > 65 years or has any contraindication to anticoagulants; then bioprosetheses are preferred (biologic valve).
 
Age is not a contraindication to aortic valve replacement in aortic stenosis.
 
===Low Flow Aortic Stenosis===
If there is a decline in left ventricular function due to systolic dysfunction, there may be only a moderate transvalvular gradient or low flow aortic stenosis.  If there is fibrosis of the left ventricle, there may be incomplete recovery after aortic valve replacement. This scenario can also occur among patients in whom there is a history of myocardial infarction; there is insufficient contractility to mount an aortic gradient.
====Definition====
#An aortic valve areas < 1.0 cm<sup>2</sup>
#A left ventricular ejection fraction < 40%
#A mean pressure difference or gradient across the aortic valve of < 30 mm Hg
 
With a dobutamine infusion, the aortic valve area should increase to > 1.2 cm<sup>2</sup>, and the mean pressure gradient should rise above 30 mm Hg.  If there is a failure to acheive these improvements, early surgical mortality is 32–33%, but it is only 5–7% in those patients who can augment their contractility and gradient. Survival at five years was 88% after surgery if the patient can augment their contractility, but only 10–25% if the patient cannot augment their contractility.
 
It should be noted that left ventricular contractile reserve is a better predictor of surgical outcomes than  markers of stenosis. Aortic valve surgery is indicated if there is severe AS along with an increase in the systolic velocity integral by >20% during a dobutamine infusion.
 
==AHA/ACC 2014 Guideline for the Management of Patients With Valvular Heart Diseases==
 
===Timing of Intervention===
 
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class I]]
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1. '''[[AVR]] is recommended with severe high-gradient [[AS]] who have symptoms by history or on exercise testing ([[Aortic stenosis stages|stage D1]])([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2. '''[[AVR]] is recommended for asymptomatic patients with severe [[AS]] ([[Aortic stenosis stages|stage C2]])and LVEF <50% ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made  based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[intervention]]<br>
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed<br>  
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3. '''[[AVR]] is indicated for patients with severe [[AS]] ([[Aortic stenosis stages|stage C or D]]) when undergoing other cardiac surgery ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|}
 
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]]<br>
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors<br>
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]]<br> 
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[AVR]] is reasonable for asymptomatic patients with very severe [[AS]] ([[Aortic stenosis stages|stage C1]], aortic velocity ≥5.0 m/s) and low surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2. '''[[AVR]] is reasonable in asymptomatic patients ([[Aortic stenosis stages|stage C1]]) with severe [[AS]] and decreased exercise tolerance or an exercise fall in [[BP]] ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3. '''[[AVR]] is reasonable in symptomatic patients with low-flow/low-gradient severe [[AS]] with reduced LVEF ([[Aortic stenosis stages|stage D2]]) with a low-dose [[dobutamine]] stress study that shows an aortic velocity ≥ 4.0 m/s (or mean pressure gradient ≥ 40 mm Hg) with a valve area ≤ 1.0 cm2 at any [[dobutamine]] dose ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4. '''[[AVR]] is reasonable in symptomatic patients who have low-flow/low-gradient severe AS ([[Aortic stenosis stages|stage D3]]) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5. '''[[AVR]] is reasonable for patients with moderate [[AS]] ([[Aortic stenosis stages|stage B]]) (aortic velocity 3.0–3.9 m/s) who are undergoing other [[cardiac surgery]] ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}
 
{|
{|class="wikitable"
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[AVR]] may be considered for asymptomatic patients with severe [[AS]] ([[Aortic stenosis stages|stage C1]]) and rapid disease progression and low surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}
<span style="font-size:85%">'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]


===Choice of Surgical or Transcatheter Intervention===
</span>
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1. '''Surgical [[AVR]] is recommended in patients who meet an indication for [[AVR]] with low or intermediate surgical risk. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2. '''For patients in whom [[Transcatheter aortic valve implantation|TAVR]] or high-risk surgical [[AVR]] is being considered, members of a Heart Valve Team should collaborate to provide optimal patient care ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3. '''[[Transcatheter aortic valve implantation|TAVR]] is recommended in patients who meet an indication for [[AVR]] for [[AS]] who have a prohibitive surgical risk and a predicted post-TAVR survival >12 months ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[Transcatheter aortic valve implantation|TAVR]] is a reasonable alternative to surgical [[AVR]] in patients who meet an indication for [[AVR]]  and who have high surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[Aortic stenosis valvuloplasty|Percutaneous aortic balloon dilation]] may be considered as a bridge to surgical or transcatheter AVR in severely symptomatic patients with severe [[AS]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[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#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
==2008 Focused Update Incorporated Into the 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |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 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==
 
===Aortic Valve Replacement Indications (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |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 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[AVR]] is indicated for symptomatic patients with severe [[AS]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[AVR]] is indicated for patients with severe [[AS]] undergoing [[CABG|coronary artery bypass graft surgery]] (CABG). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[AVR]] is indicated for patients with severe [[AS]] undergoing surgery on the [[aorta]] or other [[heart valves]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])''<nowiki>"</nowiki>
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' [[Aortic valve replacement]] is indicated for patients with severe [[AS]] and [[LV dysfunction]] (LV ejection fraction less than 50%). ''([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])''<nowiki>"</nowiki>
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' In patients with bicuspid valves undergoing [[AVR]] because of severe [[AS]] or [[AR]], repair of the                                      [[aortic root]] or replacement of the [[ascending aorta]] is indicated if the diameter of the [[aortic root]] or [[ ascending aorta]] is greater                                      than 4.5 cm. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[AVR]] is not useful for the prevention of sudden death in asymptomatic patients with [[AS]] who have none of the findings listed under the Class IIa/IIb recommendations''([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[AVR]] is reasonable for patients with moderate [[AS]] undergoing [[CABG]] or surgery on the [[aorta]] or other [[heart valves]].'' ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
 
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[AVR]] may be considered for asymptomatic patients with severe [[AS]] and abnormal response to exercise (e.g., development of symptoms or asymptomatic [[hypotension]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[AVR]] may be considered for adults with severe asymptomatic [[AS]] if there is a high likelihood of rapid progression (age, [[Calcific aortic valve disease|calcification]], and [[CAD]]) or if surgery might be delayed at the time of symptom onset. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[AVR]] may be considered in patients undergoing [[CABG]] who have mild [[AS]] when there is evidence, such as moderate to severe [[Calcific aortic valve disease|valve calcification]], that progression may be rapid. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' [[AVR]] may be considered for asymptomatic patients with extremely severe [[AS]] (aortic valve area less than 0.6 cm2, mean gradient greater than 60 mm Hg, and jet velocity greater than 5.0 m per second) when the patient's expected operative mortality is 1.0% or less. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


==References==
==References==

Latest revision as of 13:52, 14 December 2022

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Risk calculators and risk factors for Aortic stenosis surgery indications

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Mohammed A. Sbeih, M.D. [3]; Usama Talib, BSc, MD [4] Synonyms and keywords: As; Aortic stenosis; AVR; Aortic valve replacement; LVEF; Left ventricular ejection fraction; LV; Left ventricle

Overview

In symptomatic patients with severe high-gradient AS (Stage D1), AVR has beneficial effect on survival, symptoms, and LV systolic function. In asymptomatic patients with severe AS and normal LV systolic function, the risk of sudden death (<1% per year) is low. In patients with a low LVEF and severe AS, survival is better with AVR than medical therapy.

Indications

. The rate of symptom onset is strongly dependent on the severity of AS.

2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[8]

Therapeutic Recommendations for Subaortic Stenosis

Class I
1. Surgical intervention is recommended for adults with subAS, a maximum gradient 50 mm Hg or more and symptoms attributable to the subAS.(Level of Evidence: C-EO)
2.Surgical intervention is recommended for adults with subAS and less than 50 mm Hg maximum gradient and HF or ischemic symptoms, and/or LV systolic dysfunction attributable to subAS.

(Level of Evidence: C-LD)

Class IIb
1.To prevent the progression of AR, surgical intervention may be considered for asymptomatic adults with subAS and at least mild AR and a maximum gradient of 50 mm Hg or more.

(Level of Evidence: C-LD)





Recommendations for intervention in aortic stenosis
Symptomatic aortic stenosis:
(Class I, Level of Evidence B):

❑ Intervention is considered in symptomatic patients with severe, high-gradient aortic stenosis, mean gradient ≥ 40 mmHg, peak velocity ≥ 4.0 m/s, and valve area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2)
❑ntervention is considered in symptomatic patients with severe low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) aortic stenosis with reduced ejection fraction (<50%), and evidence of flow (contractile) reserve

(Class IIa, Level of Evidence C):

❑ Intervention is recommended in symptomatic severe AS with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction
❑ Intervention is recommended in symptomatic patients with low-flow, low-gradient severe aortic stenosis and reduced ejection fraction without flow (contractile) reserve, severe aortic stenosis proven by CCT calcium score

(Class III, Level of Evidence C) :

❑ Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year

Asymptomatic severe aortic stenosis :
(Class I, Level of Evidence B):

❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) without another cause

(Class I, Level of Evidence C):

❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis, symptomtomatic on exercise testing

(Class IIa, Level of Evidence B):

❑ Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause

(Class IIa, Level of Evidence C):

❑ Interventin is recommended in asymptomatic patients with severe aortic stenosis and a sustained fall inblood pressure (>20 mmHg) during exercise testing

(Class IIa, Level of Evidence B):

❑Intervention is considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and in the presence of one of the following:

Type of intervention:
(Class I, Level of Evidence C):

❑Aortic valve interventions should be performed in an experienced center

(Class I, Level of Evidence B):

❑SAVR is recommended in younger patients who are low risk for surgery (<75 yearse and STS PROM/EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI
❑SAVR or TAVI are recommended for patients based on clinical, anatomical, and procedural characteristics

(Class I, Level of Evidence A):

❑TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for surgery

(Class IIb, Level of Evidence C):

❑ Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI
❑Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in hemodynamically unstable patients and (if feasible) in those with severe aortic stenosis who require urgent high risk non-cardiac surgery

Abbreviations: BNP: B-type natriuretic peptide; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; CCT:Cardiac computed tomography; SAVR: Surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons - predicted risk of mortality; SVi: Stroke volume index; TAVI:Transcatheter aortic valve implantation ; Vmax:Peak transvalvular velocity


The above table adopted from 2021 ESC Guideline[9]


 
 
 
 
Valvular AS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low-gradient AS
  • Vmax < 4 m/s
  • ΔPm < 40 mmHg
 
 
 
High-gradient AS
  • Vmax ≥ 4 m/s,
  • ΔPm ≥ 40 mmHg
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		AVA ≤ 1.0 cm2
     
     
     
     
    		High flow status
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		Yes
     
    		NO
  • Moderate AS
    •  
    		Yes
  • Assessment of normal flow condition
    •  
     
    		NO
  • Severe AS
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Normal flow
     
    		Low flow
  • SVi ≤ 35 mL/m2
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Severe AS unlikely
     
    		LVEF ≥ 50%
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		NO
     
    		Yes
  • CCT to assess AV calcification
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO, CCT to assess AV calcification
     
    		Yes, AVA ≤ 1.0 cm2
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		Yes
     
    		NO
  • Pseudo-severe AS
    •  
     
     
     
     
     
     
     
     
     
     
     

    Abbreviations: AS: Aortic stenosis; AV: Aortic valve; AVA: Aortic valve area; LVEF: Left ventricular ejection fraction ; CT: Computed tomography; △Pm: Mean pressure gradient; DSE: Dobutamine stress echocardiography; LV: Left ventricular; SVi: Stroke volume index; Vmax: Peak transvalvular velocity



    The above table adopted from 2021 ESC Guideline[9]


    Recommendations for choice of Mechanical Versus Bioprosthetic AVR
    (Class I, Level of Evidence C):

    ❑ Decision should be made based on patients preference and values after discussion about the risks of anticoagulant therapy or the need for valve intervention
    ❑ Bioprothesis AVR is recommended when anticoagulant theray with VKA is contraindicated, not desired, or can not be managed

    (Class IIa, Level of Evidence B):

    ❑Mechanical aortic prothesis is preferred over bioprosthetic valve for patients < 50 years of age and no contraindication of anticoagulant therapy
    ❑For patients 50-65 years of age without contraindication of anticoagulant therapy, choosing either mechanical or bioprothesis aortic valve should be individualized based on patient factors
    ❑ For patients > 65 years of age, bioprosthetic aortic valve is preferred over mechanical aortic valve

    (Class IIb, Level of Evidence B):

    ❑For patients <50 years of age who desire bioprosthetic valve and appropriate anatomy, the Rose procedure including replacement of aortic valve by a pulmonic autograft may be considered

    The above table adopted from 2020 AHA Guideline[11]

    Abbreviations: AVR: Aortic valve replacement; VKA: Vitamin K antagonist

    References

    1. ↑ Rosenhek R, Binder T, Porenta G, Lang I, Christ G, Schemper M, Maurer G, Baumgartner H (August 2000). "Predictors of outcome in severe, asymptomatic aortic stenosis". N Engl J Med. 343 (9): 611–7. doi:10.1056/NEJM200008313430903. PMID 10965007.
    2. ↑ Tribouilloy C, Lévy F, Rusinaru D, Guéret P, Petit-Eisenmann H, Baleynaud S, Jobic Y, Adams C, Lelong B, Pasquet A, Chauvel C, Metz D, Quéré JP, Monin JL (May 2009). "Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography". J Am Coll Cardiol. 53 (20): 1865–73. doi:10.1016/j.jacc.2009.02.026. PMID 19442886.
    3. ↑ Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G (January 2010). "Natural history of very severe aortic stenosis". Circulation. 121 (1): 151–6. doi:10.1161/CIRCULATIONAHA.109.894170. PMID 20026771.
    4. ↑ Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, Binder T, Pacher R, Maurer G, Baumgartner H (May 2004). "Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis". Circulation. 109 (19): 2302–8. doi:10.1161/01.CIR.0000126825.50903.18. PMID 15117847.
    5. ↑ Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Murakami T, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Sakata R, Kimura T (December 2015). "Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis". J Am Coll Cardiol. 66 (25): 2827–2838. doi:10.1016/j.jacc.2015.10.001. PMID 26477634.
    6. ↑ Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, Yun SC, Hong GR, Song JM, Chung CH, Song JK, Lee JW, Park SW (January 2020). "Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis". N Engl J Med. 382 (2): 111–119. doi:10.1056/NEJMoa1912846. PMID 31733181.
    7. ↑ Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kadota K, Izumi C, Nakatsuma K, Sasa T, Watanabe H, Kuwabara Y, Makiyama T, Ono K, Shizuta S, Kato T, Saito N, Minatoya K, Kimura T (January 2018). "Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis". JACC Cardiovasc Interv. 11 (2): 145–157. doi:10.1016/j.jcin.2017.08.036. PMID 29289632.
    8. ↑ Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM; et al. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J Am Coll Cardiol. 73 (12): 1494–1563. doi:10.1016/j.jacc.2018.08.1028. PMID 30121240.
    9. ↑ 9.0 9.1 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
    10. ↑ Fougères E, Tribouilloy C, Monchi M, Petit-Eisenmann H, Baleynaud S, Pasquet A, Chauvel C, Metz D, Adams C, Rusinaru D, Guéret P, Monin JL (October 2012). "Outcomes of pseudo-severe aortic stenosis under conservative treatment". Eur Heart J. 33 (19): 2426–33. doi:10.1093/eurheartj/ehs176. PMID 22733832.
    11. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).

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