Aortic stenosis general approach

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Aortic Stenosis Microchapters


Patient Information


Historical Perspective




Differentiating Aortic Stenosis from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis


History and Symptoms

Physical Examination

Cardiac Stress Test


Chest X Ray




Cardiac Catheterization

Aortic Valve Area

Aortic Valve Area Calculation


General Approach

Medical Therapy


Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty

Transcatheter Aortic Valve Replacement (TAVR)

Critical Pathway
Patient Selection
Valve Types
TAVR Procedure
Post TAVR management
AHA/ACC Guideline Recommendations

Follow Up


Precautions and Prophylaxis

Cost-Effectiveness of Therapy

Future or Investigational Therapies

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Case #1

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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


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
Reduction in systolic opening
Severe aortic stenosis:
ΔPmean≥40 mmHg
Vmax3-3.9 m/s
ΔPmean20-39 mmHg
Is the patient symptomatic?
Is the patient symptomatic?
(Stage D1)
(Stage C)
(Stage B)
LVEF <50%
(Stage C2)
Is LVEF <50%?
The patient is undergoing
another cardiac surgery
The patient is undergoing
another cardiac surgery
ΔPmean≥60 mmHg
(Very severe stage C1)
Low surgical risk
Dobutamine stress echocardiography:
Aortic valve area ≤1 cm2
Vmax≥4 ms
(Stage D2)
Aortic valve area ≤1 cm2
LVEF ≥50%
(Stage D3)
Abnormal exercise treadmill test
The symptoms are likely
the result of the aortic stenosis
ΔVmax>0.3 m/s/y
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
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]

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]

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]

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
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:; EuroSCORE II (calculator:; logistic EuroSCORE I (calculator:; 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.


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