Aortic stenosis general approach

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]; Sabawoon Mirwais, M.B.B.S, M.D.[3]; Rim Halaby; Usama Talib, BSc, MD [4]; Arooj Naz, M.B.B.S

Overview

Once a patient with aortic stenosis becomes symptomatic, aortic valve replacement should be performed as long as the patient can tolerate surgery and has no co-morbidities. If severe left ventricular dysfunction is present in the setting of aortic stenosis, it is of utmost importance to differentiate between true severe aortic stenosis and pseudo-severe aortic stenosis as these two entities have different pathophysiologies and different outcomes after aortic valve replacement.[1] Medical therapy reduces symptoms but does not prolong life. If a patient has extensive co-morbidities, transcatheter aortic valve implantation can be considered. Aortic valvuloplasty can be considered in those patients who are too sick for surgery or transcatheter aortic valve implantation.[2]

General Approach

The general approach to treating Aortic Valve Stenosis has the following important aspects.[3]

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.[5][6]

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)

Shown below is an algorithm summarizing the approach to patients with low flow, low gradient aortic stenosis.[1]

Abbreviations: AVR: Aortic valve replacement; EOA: Effective orifice area; ΔPmean: mean pressure gradient

 
 
Ultrasound evaluation of aortic stenosis
Effective orifice area (EOA)≤ 1 cm2
Pressure gradient (ΔP)<40 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low grade low flow aortic stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal left ventricular ejection fraction
 
Left ventricular ejection fraction≤ 40-50%[6]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No specific recommendations:
- Surgical AVR, or
- Transcather AVR, or
- Medical treatment
 
 
 
 
 
 
 
 
 
 
 
Dobutamine stress test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increase in stroke volume by ≥ 20%
 
Increase in stroke volume by <20%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of left ventricular flow reserve
 
Absence of left ventricular flow reserve
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ΔP≥40
EOA<1-1.2
 
ΔP<40
EOA≥1-1.2
 
EOA<1-1.2
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
True severe aortic stenosis
 
Pseudo-severe aortic stenosis
 
True severe aortic stenosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical AVR
with/without CABG
 
Medical treatment
Close follow up
 
Transcather AVR


Available Therapeutic Options

Following are some of the available therapeutic options for Aortic Stenosis.[3][7]

ESC/EACTS Guidelines

Indications for Intervention in Aortic Stenosis and Recommendations for the Choice of Intervention Mode[8]


Symptomatic Aortic Stenosis Class of Recommendation Level of Evidence
Intervention is indicated in symptomatic patients with severe, high-gradient aortic stenosis (mean gradient ≥ 40 mmHg or peak velocity ≥ 4.0 m/s)[9][10][11] and valve area <1.0 cm² (or <0.6 cm²/m²)[12] I B
Intervention is indicated 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 excluding pseudosevere aortic stenosis I B
Intervention should be considered in symptomatic patients with low-flow, low-gradient (< 40 mmHg) aortic stenosis with normal ejection fraction after careful confirmation of severe aortic stenosis IIa C
Intervention should be considered in symptomatic patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction without flow (contractile) reserve, particularly when CT calcium scoring confirms severe aortic stenosis IIa C
Intervention should not be performed in patients with severe comorbidities when the intervention is unlikely to improve quality of life or survival >1 year III C
Choice of Intervention in Symptomatic Aortic Stenosis
Aortic valve interventions must be performed in Heart Valve Centres that declare their local expertise and outcomes data, have active interventional cardiology and cardiac surgical programmes on site, and a structured collaborative Heart Team approach[13] I C
The choice between surgical and transcatheterintervention must be based upon careful evaluation of clinical, anatomical, and procedural factors by the Heart Team, weighing the risks and benefits of each approach for an individual patient. The Heart Team recommendation

should be discussed with the patient who can then make an informed treatment choice[13]

I C
SAVR is recommended in younger patients who are low risk for surgery (<75 years and STS-PROM/EuroSCORE II <4%), or in patients

who are operable and unsuitable for transfemoral TAVI[13]

I B
TAVI is recommended in older patients (>75 years), or in those who are high risk (STS- PROM/EuroSCORE Il >8%) or unsuitable for surgery[9][14][13] I A
SAVR or TAVI are recommended for remaining patients according to individual clinical, anatomical, and procedural characteristics.[13] In patients who are at increased surgical risk (STS or EuroSCORE II ≥ 4% or logistic EuroSCORE I ≥ 10%b or other risk factors not included in these scores such as frailty, porcelain aorta, sequelae of chest radiation), the decision between SAVR and TAVR should be made by the Heart Team according to the individual patient characteristics, with TAVR being favored in elderly patients suitable for transfemoral access[9][14][15][16][17][18][19][20][21][22] I B
Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI[23] IIb C
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 higher risk NCS[24] IIb C
Asymptomatic Patients With Severe Aortic Stenosis (Refers Only to Patients Eligible for Surgical Valve Replacement)
Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <50%) without another cause[25] I B
Intervention is recommended in asymptomatic patients with severe aortic stenosis and demonstrable symptoms on exercise testing I C
Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without

another cause[26]

IIa B
Intervention should be considered in asymptomatic patients with severe aortic stenosis and a sustained fall in BP (>20 mmHg) during exercise testing[27] IIa C
Intervention should be considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and one of the following parameters is present:[28]
  • Very severe aortic stenosis (mean gradient ≥60 mmHg or Vmax >5 m/S)
  • Severe valve calcification (ideally assessed by CCT) and Vmax progression ≥0.3 m/s/year
  • Markedly elevated BNP levels (> threefold age- and sex-corrected normal range) confirmed by repeated measurements without other explanations
  • Severe pulmonary hypertension (systolic pulmonary artery pressure at rest > 60 mmHg confirmed by invasive measurement) without other explanation
 IIa B
Concomitant Aortic Valve Surgery at the Time of Other Cardiac/Ascending Aorta Surgery
SAVR is recommended in patients with severe aortic stenosis undergoing CABG or surgical intervention on the ascending aorta or another valve[29] I C
SAVR should be considered in patients with moderate aortic stenosis" undergoing CABG or surgical intervention on the ascending aorta or another valve after Heart Team discussion[30] IIa C
BNP = B-type natriuretic peptide; CABG = coronary artery bypass grafting; CT = computed tomography; EuroSCORE = European System for Cardiac Operative Risk Evaluation; LV = left ventricular; LVEF = left ventricular ejection fraction; SAVR = surgical aortic valve replacement; STS = Society of Thoracic Surgeons; TAVR = transcatheter aortic valve replacement; Vmax = peak transvalvular velocity
  • aIn patients with a small valve area but low gradient despite preserved LVEF, explanations for this finding other than the presence of severe aortic stenosis are frequent and must be carefully excluded.
  • bSTS score (calculator: http://riskcalc.sts.org/stswebriskcalc/#/calculate); EuroSCORE II (calculator: http://www.euroscore.org/calc.html); logistic EuroSCORE I (calculator:http://www.euroscore.org/calcge.html); scores have major limitations for practical use in this setting by insufficiently considering disease severity and not including major risk factors such as frailty, porcelain aorta, chest radiation, etc. EuroSCORE I markedly overestimates 30-day mortality and should therefore be replaced by the better-performing EuroSCORE II with this regard; it is nevertheless provided here for comparison, as it has been used in many TAVR studies/registries and may still be useful to identify the subgroups of patients for decision between intervention modalities and to predict 1-year mortality.
  • cModerate aortic stenosis is defined as a valve area of 1.0–1.5 cm2 or a mean aortic gradient of 25–40 mmHg in the presence of normal flow conditions. However, clinical judgement is required.

References

  1. ↑ 1.0 1.1 Pibarot P, Dumesnil JG (2012). "Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction". J Am Coll Cardiol. 60 (19): 1845–53. doi:10.1016/j.jacc.2012.06.051. PMID 23062546.
  2. ↑ Franck Levy, Marcel Laurent, Jean Luc Monin, Jean Michel Maillet, Agnes Pasquet, Thierry Le Tourneau, Helene Petit-Eisenmann, Mauro Gori, Yannick Jobic, Fabrice Bauer, Christophe Chauvel, Alain Leguerrier & Christophe Tribouilloy (2008). "Aortic valve replacement for low-flow/low-gradient aortic stenosis operative risk stratification and long-term outcome: a European multicenter study". Journal of the American College of Cardiology. 51 (15): 1466–1472. doi:10.1016/j.jacc.2007.10.067. PMID 18402902. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.
  4. ↑ Jean-Luc Monin, Jean-Paul Quere, Mehran Monchi, Helene Petit, Serge Baleynaud, Christophe Chauvel, Camelia Pop, Patrick Ohlmann, Claude Lelguen, Patrick Dehant, Christophe Tribouilloy & Pascal Gueret (2003). "Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics". Circulation. 108 (3): 319–324. doi:10.1161/01.CIR.0000079171.43055.46. PMID 12835219. Unknown parameter |month= ignored (help)
  5. ↑ 5.0 5.1 Bonow RO, Carabello B, de Leon AC, Edmunds LH, Fedderly BJ, Freed MD; et al. (1998). "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)". J Heart Valve Dis. 7 (6): 672–707. PMID 9870202.
  6. ↑ 6.0 6.1 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.
  7. ↑ Vahl TP, Kodali SK, Leon MB (2016). "Transcatheter Aortic Valve Replacement 2016: A Modern-Day "Through the Looking-Glass" Adventure". J Am Coll Cardiol. 67 (12): 1472–87. doi:10.1016/j.jacc.2015.12.059. PMID 27012409.
  8. ↑ Baumgartner, Helmut; Falk, Volkmar; Bax, Jeroen J; De Bonis, Michele; Hamm, Christian; Holm, Per Johan; Iung, Bernard; Lancellotti, Patrizio; Lansac, Emmanuel; Rodriguez Muñoz, Daniel; Rosenhek, Raphael; Sjögren, Johan; Tornos Mas, Pilar; Vahanian, Alec; Walther, Thomas; Wendler, Olaf; Windecker, Stephan; Zamorano, Jose Luis; Roffi, Marco; Alfieri, Ottavio; Agewall, Stefan; Ahlsson, Anders; Barbato, Emanuele; Bueno, Héctor; Collet, Jean-Philippe; Coman, Ioan Mircea; Czerny, Martin; Delgado, Victoria; Fitzsimons, Donna; Folliguet, Thierry; Gaemperli, Oliver; Habib, Gilbert; Harringer, Wolfgang; Haude, Michael; Hindricks, Gerhard; Katus, Hugo A; Knuuti, Juhani; Kolh, Philippe; Leclercq, Christophe; McDonagh, Theresa A; Piepoli, Massimo Francesco; Pierard, Luc A; Ponikowski, Piotr; Rosano, Giuseppe M C; Ruschitzka, Frank; Shlyakhto, Evgeny; Simpson, Iain A; Sousa-Uva, Miguel; Stepinska, Janina; Tarantini, Giuseppe; Tchétché, Didier; Aboyans, Victor; Windecker, Stephan; Aboyans, Victor; Agewall, Stefan; Barbato, Emanuele; Bueno, Héctor; Coca, Antonio; Collet, Jean-Philippe; Coman, Ioan Mircea; Dean, Veronica; Delgado, Victoria; Fitzsimons, Donna; Gaemperli, Oliver; Hindricks, Gerhard; Iung, Bernard; Jüni, Peter; Katus, Hugo A; Knuuti, Juhani; Lancellotti, Patrizio; Leclercq, Christophe; McDonagh, Theresa; Piepoli, Massimo Francesco; Ponikowski, Piotr; Richter, Dimitrios J; Roffi, Marco; Shlyakhto, Evgeny; Simpson, Iain A; Zamorano, Jose Luis; Kzhdryan, Hovhannes K; Mascherbauer, Julia; Samadov, Fuad; Shumavets, Vadim; Camp, Guy Van; Lončar, Daniela; Lovric, Daniel; Georgiou, Georgios M; Linhartova, Katerina; Ihlemann, Nikolaj; Abdelhamid, Magdy; Pern, Teele; Turpeinen, Anu; Srbinovska-Kostovska, Elizabeta; Cohen, Ariel; Bakhutashvili, Zviad; Ince, Hüseyin; Vavuranakis, Manolis; Temesvári, András; Gudnason, Thorarinn; Mylotte, Darren; Kuperstein, Rafael; Indolfi, Ciro; Pya, Yury; Bajraktari, Gani; Kerimkulova, Alina; Rudzitis, Ainars; Mizariene, Vaida; Lebrun, Frédéric; Demarco, Daniela Cassar; Oukerraj, Latifa; Bouma, Berto J; Steigen, Terje Kristian; Komar, Monika; De Moura Branco, Luisa Maria; Popescu, Bogdan A; Uspenskiy, Vladimir; Foscoli, Marina; Jovovic, Ljiljana; Simkova, Iveta; Bunc, Matjaz; de Prada, José Antonio Vázquez; Stagmo, Martin; Kaufmann, Beat Andreas; Mahdhaoui, Abdallah; Bozkurt, Engin; Nesukay, Elena; Brecker, Stephen J D (2017). "2017 ESC/EACTS Guidelines for the management of valvular heart disease". European Heart Journal. 38 (36): 2739–2791. doi:10.1093/eurheartj/ehx391. ISSN 0195-668X.
  9. ↑ 9.0 9.1 9.2 Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Brown DL, Block PC, Guyton RA, Pichard AD, Bavaria JE, Herrmann HC, Douglas PS, Petersen JL, Akin JJ, Anderson WN, Wang D, Pocock S (October 2010). "Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery". N. Engl. J. Med. 363 (17): 1597–607. doi:10.1056/NEJMoa1008232. PMID 20961243.
  10. ↑ 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.
  11. ↑ Thourani VH, Suri RM, Gunter RL, Sheng S, O'Brien SM, Ailawadi G, Szeto WY, Dewey TM, Guyton RA, Bavaria JE, Babaliaros V, Gammie JS, Svensson L, Williams M, Badhwar V, Mack MJ (January 2015). "Contemporary real-world outcomes of surgical aortic valve replacement in 141,905 low-risk, intermediate-risk, and high-risk patients". Ann. Thorac. Surg. 99 (1): 55–61. doi:10.1016/j.athoracsur.2014.06.050. PMID 25442986.
  12. ↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
  13. ↑ 13.0 13.1 13.2 13.3 13.4 https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
  14. ↑ 14.0 14.1 Deeb GM, Reardon MJ, Chetcuti S, Patel HJ, Grossman PM, Yakubov SJ, Kleiman NS, Coselli JS, Gleason TG, Lee JS, Hermiller JB, Heiser J, Merhi W, Zorn GL, Tadros P, Robinson N, Petrossian G, Hughes GC, Harrison JK, Maini B, Mumtaz M, Conte J, Resar J, Aharonian V, Pfeffer T, Oh JK, Qiao H, Adams DH, Popma JJ (June 2016). "3-Year Outcomes in High-Risk Patients Who Underwent Surgical or Transcatheter Aortic Valve Replacement". J. Am. Coll. Cardiol. 67 (22): 2565–74. doi:10.1016/j.jacc.2016.03.506. PMID 27050187.
  15. ↑ Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ (June 2011). "Transcatheter versus surgical aortic-valve replacement in high-risk patients". N. Engl. J. Med. 364 (23): 2187–98. doi:10.1056/NEJMoa1103510. PMID 21639811.
  16. ↑ Mack MJ, Leon MB, Smith CR, Miller DC, Moses JW, Tuzcu EM, Webb JG, Douglas PS, Anderson WN, Blackstone EH, Kodali SK, Makkar RR, Fontana GP, Kapadia S, Bavaria J, Hahn RT, Thourani VH, Babaliaros V, Pichard A, Herrmann HC, Brown DL, Williams M, Akin J, Davidson MJ, Svensson LG (June 2015). "5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial". Lancet. 385 (9986): 2477–84. doi:10.1016/S0140-6736(15)60308-7. PMID 25788234.
  17. ↑ Adams DH, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, Gleason TG, Buchbinder M, Hermiller J, Kleiman NS, Chetcuti S, Heiser J, Merhi W, Zorn G, Tadros P, Robinson N, Petrossian G, Hughes GC, Harrison JK, Conte J, Maini B, Mumtaz M, Chenoweth S, Oh JK (May 2014). "Transcatheter aortic-valve replacement with a self-expanding prosthesis". N. Engl. J. Med. 370 (19): 1790–8. doi:10.1056/NEJMoa1400590. PMID 24678937.
  18. ↑ Thyregod H, Ihlemann N, Jørgensen TH, Nissen H, Kjeldsen BJ, Petursson P, Chang Y, Franzen OW, Engstrøm T, Clemmensen P, Hansen PB, Andersen LW, Steinbrüchel DA, Olsen PS, Søndergaard L (February 2019). "Five-Year Clinical and Echocardiographic Outcomes from the Nordic Aortic Valve Intervention (NOTION) Randomized Clinical Trial in Lower Surgical Risk Patients". Circulation. doi:10.1161/CIRCULATIONAHA.118.036606. PMID 30704298. Vancouver style error: initials (help)
  19. ↑ Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, Thourani VH, Tuzcu EM, Miller DC, Herrmann HC, Doshi D, Cohen DJ, Pichard AD, Kapadia S, Dewey T, Babaliaros V, Szeto WY, Williams MR, Kereiakes D, Zajarias A, Greason KL, Whisenant BK, Hodson RW, Moses JW, Trento A, Brown DL, Fearon WF, Pibarot P, Hahn RT, Jaber WA, Anderson WN, Alu MC, Webb JG (April 2016). "Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients". N. Engl. J. Med. 374 (17): 1609–20. doi:10.1056/NEJMoa1514616. PMID 27040324.
  20. ↑ Vinod H. Thourani, Susheel Kodali, Raj R. Makkar, Howard C. Herrmann, Mathew Williams, Vasilis Babaliaros, Richard Smalling, Scott Lim, S. Chris Malaisrie, Samir Kapadia, Wilson Y. Szeto, Kevin L. Greason, Dean Kereiakes, Gorav Ailawadi, Brian K. Whisenant, Chandan Devireddy, Jonathon Leipsic, Rebecca T. Hahn, Philippe Pibarot, Neil J. Weissman, Wael A. Jaber, David J. Cohen, Rakesh Suri, E. Murat Tuzcu, Lars G. Svensson, John G. Webb, Jeffrey W. Moses, Michael J. Mack, D. Craig Miller, Craig R. Smith, Maria C. Alu, Rupa Parvataneni, Ralph B. Jr D'Agostino & Martin B. Leon (2016). "Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis". Lancet (London, England). 387 (10034): 2218–2225. doi:10.1016/S0140-6736(16)30073-3. PMID 27053442. Unknown parameter |month= ignored (help)
  21. ↑ George C. M. Siontis, Fabien Praz, Thomas Pilgrim, Dimitris Mavridis, Subodh Verma, Georgia Salanti, Lars Sondergaard, Peter Juni & Stephan Windecker (2016). "Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of severe aortic stenosis: a meta-analysis of randomized trials". European heart journal. 37 (47): 3503–3512. doi:10.1093/eurheartj/ehw225. PMID 27389906. Unknown parameter |month= ignored (help)
  22. ↑ Michael J. Reardon, Nicolas M. Van Mieghem, Jeffrey J. Popma, Neal S. Kleiman, Lars Sondergaard, Mubashir Mumtaz, David H. Adams, G. Michael Deeb, Brijeshwar Maini, Hemal Gada, Stanley Chetcuti, Thomas Gleason, John Heiser, Rudiger Lange, William Merhi, Jae K. Oh, Peter S. Olsen, Nicolo Piazza, Mathew Williams, Stephan Windecker, Steven J. Yakubov, Eberhard Grube, Raj Makkar, Joon S. Lee, John Conte, Eric Vang, Hang Nguyen, Yanping Chang, Andrew S. Mugglin, Patrick W. J. C. Serruys & Arie P. Kappetein (2017). "Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients". The New England journal of medicine. 376 (14): 1321–1331. doi:10.1056/NEJMoa1700456. PMID 28304219. Unknown parameter |month= ignored (help)
  23. ↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
  24. ↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
  25. ↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
  26. ↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
  27. ↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
  28. ↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
  29. ↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
  30. ↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)

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