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Aortic Stenosis Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

Aortic Stenosis

Choice of Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	C	For patients in whom TAVR or high-risk surgical AVR is being considered, a heart valve team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care.	2014 recommendation remains current.
I	B-NR	Surgical AR is recommended for symptomatic patients with severe AS (Stage D) and asymptomatic patients with severe AS (Stage C) who meet an indication for AVR when surgical risk is low or intermediate.	MODIFIED: LOE updated from A to B-NR. Prior recommendations for intervention choice did not specify patient symptoms. The patient population recommended for surgical AVR encompasses both symptomatic and asymptomatic patients who meet an indication for AVR with low-to-intermediate surgical risk. This is opposed to the patient population recommended for TAVR, in whom symptoms are required to be present. Thus, all recommendations for type of intervention now specify the symptomatic status of the patient.
I	A	Surgical AVR or TAVR is recommended for symptomatic patients with severe AS (Stage D) and high risk for surgical AVR, depending on patient specific procedural risks, values, and preferences.	MODIFIED: COR updated from IIa to I, LOE updated from B to A. Longer-term follow-up and additional RCTs have demonstrated that TAVR is equivalent to surgical AVR for severe symptomatic AS when surgical risk is high.
I	A	TAVR is recommended for symptomatic patients with severe AS (Stage D) and a prohibitive risk for surgical AVR who have a predicted post-TAVR survival greater than 12 months.	MODIFIED: LOE updated from B to A. Longer-term follow-up from RCTs and additional observational studies has demonstrated the benefit of TAVR in patients with a prohibitive surgical risk.
IIa	B-R	TAVR is a reasonable alternative to surgical AVR for symptomatic patients with severe AS (Stage D) and an intermediate surgical risk, depending on patient-specific procedural risks, values, and preferences.	NEW: New RCT showed noninferiority of TAVR to surgical AVR in symptomatic patients with severe AS at intermediate surgical risk.
IIb	C	Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR for symptomatic patients with severe AS.	2014 recommendation remains current.
III: No Benefit	C	TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS.	2014 recommendation remains current.

Aortic Stenosis

Aspects to be considered by the Heart Team for decision between SAVR and TAVI in patients at increased surgical risk

	FAVOURS TAVI	FAVOURS SAVR
Clinical Characteristics
STS/EuroSCORE II <4% (logistic EuroSCORE I <10%)		+
STS/EuroSCORE II ≥4% (logistic EuroSCORE I ≥10%)	+
Presence of severe comorbidity ( not adequately reflected by scores)	+
Age <75		+
Age ≥75	+
Previous cardiac surgery	+
Frailty	+
Restricted mobility and conditions that may affect the rehabilitation process after the procedure	+
Suspicion of endocarditis		+
Anatomical and technical aspects
Favourable access for transferral TAVI	+
Sequelae of chest radiation	+
Porcelain aorta	+
Presence of intact coronary bypass grafts at risk when sternotomy is performed	+
Expected patients-Prosthesis mismatch	+
Severe chest deformation or scoliosis	+
Short distance between coronary ostia and aortic valve annulus		+
Size of aortic valve annulus out of range for TAVI		+
Valve morphology (bicuspid, degree of calcification, calcification pattern) unfavourable for TAVI		+
Presence of thrombi in aorta or LV		+
Cardiac conditions in addition to aortic stenosis that require consideration for concomitant intervention
Severe CAD requiring revascularisation by CABG		+
Severe primary mitral valve disease, which could be treated surgically		+
Severe tricuspid valve disease		+
Aneurysm of the ascending aorta		+
Septal hypertrophy requiring myectomy		+

References

Recommendation for IE Prophylaxis

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
IIa	L-CD	Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following (13,15,23–29): 1. Prosthetic cardiac valves, including transcatheter- implanted prostheses and homografts. 2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords. 3. Previous IE. 4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. 5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve. || MODIFIED: LOE updated from B to C-LD. Patients with transcatheter prosthetic valves and patients with prosthetic material used for valve repair, such as annuloplasty rings and chords, were specifically identified as those to whom it is reasonable to give IE prophylaxis. This addition is based on observational studies demonstrating the increased risk of developing IE and high risk of adverse outcomes from IE in these subgroups. Categories were rearranged for clarity to the caregiver.

Recommendation for Anticoagulation for Atrial Fibrillation (AF) in patients with VHD

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B-NR	Anticoagulation with a vitamin K antagonist (VKA) is indicated for patients with rheumatic mitral stenosis (MS) and AF	MODIFIED: VKA as opposed to the direct oral anticoagulants (DOACs) are indicated in patients with AF and rheumatic MS to prevent thromboembolic events. The RCTs of DOACs versus VKA have not included patients with MS. The specific recommendation for anticoagulation of patients with MS is contained in a subsection of the topic on anticoagulation.
I	L-CD	Anticoagulation is indicated in patients with AF and a CHA2DS2-VASc score of 2 or greater with native aortic valve disease, tricuspid valve disease, or mitral regurgitation.	NEW: Post hoc subgroup analyses of large RCTs comparing DOAC versus warfarin in patients with AF have analyzed patients with native valve disease other than MS and patients who have undergone cardiac surgery. These analyses consistently demonstrated that the risk of stroke is similar to or higher than that of patients without VHD. Thus, the indication for anticoagulation in these patients should follow GDMT according to the CHA2DS2-VASc score.
IIa	L-CD	It is reasonable to use a DOAC as an alternative to a VKA in patients with AF and native aortic valve disease, tricuspid valve disease, or MR and a CHA2DS2-VASc score of 2 or greater.	NEW: Several thousand patients with native VHD (exclusive of more than mild rheumatic MS) have been evaluated in RCTs comparing DOACs versus warfarin. Subgroup analyses have demonstrated that DOACs, when compared with warfarin, appear as effective and safe in patients with VHD as in those without VHD.

Recommendations for Chronic Primary Mitral Regurgitation (MR) Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B	Mitral valve surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF greater than 30%.	2014 recommendation remains current.
I	B	Mitral valve surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30% to 60% and/or left ventricular end-systolic diameter [LVESD] ≥40 mm, stage C2)	2014 recommendation remains current.
I	B	Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet.	2014 recommendation remains current.
I	B	Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished.	2014 recommendation remains current.
I	B	Concomitant mitral valve repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications.	2014 recommendation remains current.
IIa	B	Mitral valve repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and LVESD <40 mm) in whom the likelihood of a successful and durable repair without residual MR is greater than 95% with an expected mortality rate of less than 1% when performed at a Heart Valve Center of Excellence.	2014 recommendation remains current.
IIa	L-CD	Mitral valve surgery is reasonable for asymptomatic patients with chronic severe primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) with a progressive increase in LV size or decrease in ejection fraction (EF) on serial imaging studies.	NEW: Patients with severe MR who reach an EF ≤60% or LVESD ≥40 have already developed LV systolic dysfunction, so operating before reaching these parameters, particularly with a progressive increase in LV size or decrease in EF on serial studies, is reasonable.
IIa	B	Mitral valve repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mm Hg).	2014 recommendation remains current.
IIa	C	Concomitant mitral valve repair is reasonable in patients with chronic moderate primary MR (stage B) when undergoing cardiac surgery for other indications.	2014 recommendation remains current.
IIb	C	Mitral valve surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF less than or equal to 30%.	2014 recommendation remains current.
IIb	B	Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for heart failure (HF).	2014 recommendation remains current.
IIb	B	Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for heart failure (HF).	2014 recommendation remains current.
III:Harm	B	MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless mitral valve repair has been attempted and was unsuccessful.	2014 recommendation remains current.

Recommendations for Chronic Secondary Mitral Regurgitation (MR) Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
IIa	C	Mitral valve surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR.	2014 recommendation remains current.
IIa	B-R	It is reasonable to choose chordal-sparing MVR over downsized annuloplasty repair if operation is considered for severely symptomatic patients (NYHA class III to IV) with chronic severe ischemic MR (stage D) and persistent symptoms despite GDMT for HF.	NEW: An RCT has shown that mitral valve repair is associated with a higher rate of recurrence of moderate or severe MR than that associated with mitral valve replacement (MVR) in patients with severe, symptomatic, ischemic MR, without a difference in mortality rate at 2 years' follow-up.
IIb	B	Mitral valve repair or replacement may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT for HF.	2014 recommendation remains current.
IIb	B-R	In patients with chronic, moderate, ischemic MR (stage B) undergoing CABG, the usefulness of mitral valve repair is uncertain.	MODIFIED: LOE updated from C to B-R. The 2014 recommendation supported mitral valve repair in this group of patients. An RCT showed no clinical benefit of mitral repair in this population of patients, with increased risk of postoperative complications.

Recommendations for Intervention of Prosthetic valves

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	L-CD	The choice of type of prosthetic heart valve should be a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risk associated with reintervention	MODIFIED: LOE updated from C to C-LD. In choosing the type of prosthetic valve, the potential need for and risk of “reoperation” was updated to risk associated with “reintervention.” The use of a transcatheter valve-in-valve procedure may be considered for decision making on the type of valve, but long-term follow-up is not yet available, and some bioprosthetic valves, particularly the smaller-sized valves, will not be suitable for a valve-in-valve replacement. Multiple other factors to be considered in the choice of type of valve for an individual patient; these factors are outlined in the text. More emphasis has been placed on shared decision making between the caregiver and patient.
I	C	A bioprosthesis is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired.	2014 recommendation remains current.
IIa	B-NR	An aortic or mitral mechanical prosthesis is reasonable for patients less than 50 years of age who do not have a contraindication to anticoagulation.	MODIFIED: LOE updated from B to B-NR. The age limit for mechanical prosthesis was lowered from 60 to 50 years of age.
IIa	B-NR	For patients between 50 and 70 years of age, it is reasonable to individualize the choice of either a mechanical or bioprosthetic valve prosthesis on the basis of individual patient factors and preferences, after full discussion of the trade- offs involved.	MODIFIED: Uncertainty exists about the optimum type of prosthesis (mechanical or bioprosthetic) for patients 50 to 70 years of age. There are conflicting data on survival benefit of mechanical versus bioprosthetic valves in this age group, with equivalent stroke and thromboembolic outcomes. Patients receiving a mechanical valve incur greater risk of bleeding, and those undergoing bioprosthetic valve replacement more often require repeat valve surgery.
IIa	B	A bioprosthesis is reasonable for patients more than 70 years of age.	2014 recommendation remains current.
IIb	C	Replacement of the aortic valve by a pulmonary autograft (the Ross procedure), when performed by an experienced surgeon, may be considered for young patients when VKA anticoagulation is contraindicated or undesirable.	2014 recommendation remains current.

Recommendations for Antithrombotic Therapy for Patients with Prosthetic Heart Valves

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	A	Anticoagulation with a VKA and INR monitoring is recommended in patients with a mechanical prosthetic valve.	2014 recommendation remains current.
I	B	Anticoagulation with a VKA to achieve an INR of 2.5 is recommended for patients with a mechanical bileaflet or current-generation single-tilting disc AVR and no risk factors for thromboembolism.	2014 recommendation remains current.
I	B	Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical AVR and additional risk factors for thromboembolic events (AF, previous thromboembolism, LV dysfunction, or hypercoagulable conditions) or an older-generation mechanical AVR (such as ball-in-cage)	2014 recommendation remains current.
I	B	Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical MVR.	2014 recommendation remains current.
I	A	Aspirin 75 mg to 100 mg daily is recommended in addition to anticoagulation with a VKA in patients with a mechanical valve prosthesis.	2014 recommendation remains current.
IIa	B	Aspirin 75 mg to 100 mg per day is reasonable in all patients with a bioprosthetic aortic or mitral valve.	2014 recommendation remains current.
IIa	B-NR	Anticoagulation with a VKA to achieve an INR of 2.5 is reasonable for at least 3 months and for as long as 6 months after surgical bioprosthetic MVR or AVR in patients at low risk of bleeding	MODIFIED: LOE updated from C to B-NR. Anticoagulation for all surgical tissue prostheses was combined into 1 recommendation, with extension of the duration of anticoagulation up to 6 months. Stroke risk and mortality rate are lower in patients who receive anticoagulation for up to 6 months after implantation of a tissue prosthesis than in those who have do not have anticoagulation. Anticoagulation for a tissue prosthesis is also supported by reports of valve thrombosis for patients undergoing bioprosthetic surgical AVR or MVR, a phenomenon that may be warfarin responsive.
IIb	B-R	A lower target INR of 1.5 to 2.0 may be reasonable in patients with mechanical On-X AVR and no thromboembolic risk factors	NEW:A lower target INR was added for patients with a mechanical On-X AVR and no thromboembolic risk factors treated with warfarin and low-dose aspirin. A single RCT of lower- versus standard-intensity anticoagulation in patients undergoing On-X AVR showed equivalent outcomes, but the bleeding rate in the control group was unusually high.
IIb	B-NR	Anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable for at least 3 months after TAVR in patients at low risk of bleeding	NEW:Studies have shown that valve thrombosis may develop in patients after TAVR, as assessed by multidetector computerized tomographic scanning. This valve thrombosis occurs in patients who received antiplatelet therapy alone but not in patients who were treated with VKA.
IIb	C	Clopidogrel 75 mg daily may be reasonable for the first 6 months after TAVR in addition to life-long aspirin 75 mg to 100 mg daily.	2014 recommendation remains current.
III:Harm	B	Anticoagulant therapy with oral direct thrombin inhibitors or anti-Xa agents should not be used in patients with mechanical valve prostheses.	2014 recommendation remains current.

Recommendations for Bridging Therapy for Prosthetic Valves

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	C	Continuation of VKA anticoagulation with a therapeutic INR is recommended in patients with mechanical heart valves undergoing minor procedures (such as dental extractions or cataract removal) where bleeding is easily controlled.	2014 recommendation remains current.
I	C	Temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended in patients with a bileaflet mechanical AVR and no other risk factors for thrombosis who are undergoing invasive or surgical procedures.	2014 recommendation remains current.
IIa	C-LD	Bridging anticoagulation therapy during the time interval when the INR is sub therapeutic preoperatively is reasonable on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism prevention, for patients who are undergoing invasive or surgical procedures with a 1) mechanical AVR and any thromboembolic risk factor, 2) older-generation mechanical AVR, or 3) mechanical MVR.	MODIFIED: COR updated from I to IIa, LOE updated from C to C-LD. RCTs of bridging anticoagulant therapy versus no bridging therapy for patients with AF who do not have a mechanical heart valve have shown higher risk of bleeding without a change in incidence of thromboembolic events. This may have implications for bridging anticoagulation therapy for patients with prosthetic valves.
IIa	C	Administration of fresh frozen plasma or prothrombin complex concentrate is reasonable in patients with mechanical valves receiving VKA therapy who require emergency noncardiac surgery or invasive procedures	2014 recommendation remains current.

Recommendations for Mechanical Prosthetic Valve Thrombosis Diagnosis and Follow up

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B-NR	Urgent evaluation with multimodality imaging is indicated in patients with suspected mechanical prosthetic valve thrombosis to assess valvular function, leaflet motion, and the presence and extent of thrombus.	MODIFIED: LOE updated to B-NR. Multiple recommendations for imaging in patients with suspected mechanical prosthetic valve thrombosis were combined into a single recommendation. Multimodality imaging with transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), fluoroscopy, and/or computed tomography (CT) scanning may be more effective than one imaging modality alone in detecting and characterizing valve thrombosis. Different imaging modalities are necessary because valve function, leaflet motion, and extent of thrombus should all be evaluated.

Recommendations for Mechanical Prosthetic Valve Thrombosis Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B-NR	Urgent initial treatment with either slow-infusion low-dose fibrinolytic therapy or emergency surgery is recommended for patients with a thrombosed left- sided mechanical prosthetic heart valve presenting with symptoms of valve obstruction.	MODIFIED: LOE updated to B-NR. Multiple recommendations based only on NYHA class symptoms were combined into 1 recommendation. Slow-infusion fibrinolytic therapy has higher success rates and lower complication rates than prior high-dose regimens and is effective in patients previously thought to require urgent surgical intervention. The decision for emergency surgery versus fibrinolytic therapy should be based on multiple factors, including the availability of surgical expertise and the clinical experience with both treatments.

Recommendations for Thrombotic Valve Stenosis

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	C	Repeat valve replacement is indicated for severe symptomatic prosthetic valve stenosis.	2014 recommendation remains current.
IIa	C-LD	In patients with suspected or confirmed bioprosthetic valve thrombosis who are hemodynamically stable and have no contraindications to anticoagulation, initial treatment with a VKA is reasonable (	2014 recommendation remains current.	NEW: Case series of patients presenting with bioprosthetic valve stenosis have suggested improvement in hemodynamics with VKA treatment because of resolution of thrombus on the valve leaflets.
IIa	B-NR	For severely symptomatic patients with bioprosthetic aortic valve stenosis judged by the heart team to be at high or prohibitive risk of reoperation, and in whom improvement in hemodynamics is anticipated, a transcatheter valve-in-valve procedure is reasonable.	NEW: Registries and case series have reported on the short-term outcomes and complication rates in patients with bioprosthetic AS who have undergone transcatheter valve-in-valve therapy.