Aortic stenosis general approach: Difference between revisions

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Latest revision as of 03:48, 8 December 2022

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]

The normal aortic valve has an orifice area of 4 cm². Aortic stenosis is a progressive pathology that becomes usually symptomatic when the area decreases to 1 cm². Once symptomatic, the most effective treatment for aortic stenosis is aortic valve replacement. Almost all symptomatic patients should undergo aortic valve replacement. One important exception is in the case of severe aortic stenosis with ventricle dysfunction where extensive testing should be done to differentiate between true severe aortic stenosis and pseudo-severe aortic stenosis. Patients with true severe low flow low gradient aortic stenosis benefit from aortic valve replacement, whereas patients with pseudo-severe low flow low gradient aortic stenosis might not benefit from aortic valve replacement and have higher operative mortality.
Asymptomatic patients should be followed up yearly for any new onset of symptoms. No treatment has been proven to delay the progression of aortic stenosis. Follow up with an echocardiography should be done every 1, 3, 5 years in severe, moderate and mild aortic stenosis respectively.^[4]
Patients undergoing aortic valve replacement and having co-existing multi-vessel coronary artery disease should have concomitantly CABG.^[5]

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; ΔP_mean: mean pressure gradient; V_max: maximum velocity

Abnormal aortic valve
AND
Reduction in systolic opening

Severe aortic stenosis:
V_max≥4m/s
AND
ΔP_mean≥40 mmHg

V_max3-3.9 m/s
AND
ΔP_mean20-39 mmHg

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

Yes

No

V_max≥5m/s
AND
ΔP_mean≥60 mmHg
(Very severe stage C1)
AND
Low surgical risk

Dobutamine stress echocardiography:
Aortic valve area ≤1 cm²
AND
V_max≥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

ΔV_max>0.3 m/s/y
AND
Low surgical risk

AVR (Class I)

AVR (Class IIa)

AVR (Class IIb)

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; ΔP_mean: 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]

Aortic stenosis surgery via aortic valve replacement
Transcatheter aortic valve implantation
Percutaneous aortic balloon valvotomy (PABV) or aortic valvuloplasty
Medical management

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

↑ ^1.0 ^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.
↑ 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)
↑ ^3.0 ^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.
↑ 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)
↑ ^5.0 ^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.
↑ ^6.0 ^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.
↑ 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.
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↑ ^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.
↑ 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.
↑ 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.
↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
↑ ^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)
↑ ^14.0 ^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.
↑ 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.
↑ 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.
↑ 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.
↑ 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)
↑ 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.
↑ 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)
↑ 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)
↑ 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)
↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
↑ https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)
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Template:WH Template:WS CME Category::Cardiology

[pmid23062546-1] 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)

[pmid19038677-3] 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)

[pmid9870202-5] 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.

[NishimuraOtto2014-6] 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.

[pmid27012409-7] 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.

[BaumgartnerFalk2017-8] 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.

[pmid20961243-9] 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.

[pmid10965007-10] 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.

[pmid25442986-11] 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.

[“2021-12] ttps://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950. Missing or empty |title= (help)

[“20212-13] 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)

[pmid27050187-14] 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.

[pmid21639811-15] 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.

[pmid25788234-16] 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.

[pmid24678937-17] 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.

[pmid30704298-18] 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)

[pmid27040324-19] 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)

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@@ Line 1: / Line 1: @@
 __NOTOC__
+{| class="infobox" style="float:right;"
+|-
+|[[File:Siren.gif|30px|link=Aortic stenosis resident survival guide]]||<br>||<br>
+|[[Aortic stenosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
+|}
 {{Aortic stenosis}}
-{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; [[User:Rim Halaby|Rim Halaby]]
+{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{sab}}; [[User:Rim Halaby|Rim Halaby]]; {{USAMA}}; [[User:AroojNaz|Arooj Naz, M.B.B.S]]
 ==Overview==
-Once a patient becomes symptomatic with aortic stenosis, [[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.
+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.<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>
-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.
+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.<ref>{{Cite journal
+ | author = [[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]]
+ | title = Aortic valve replacement for low-flow/low-gradient aortic stenosis operative risk stratification and long-term outcome: a European multicenter study
+ | journal = [[Journal of the American College of Cardiology]]
+ | volume = 51
+ | issue = 15
+ | pages = 1466–1472
+ | year = 2008
+ | month = April
+ | doi = 10.1016/j.jacc.2007.10.067
+ | pmid = 18402902
+}}</ref>
 ==General Approach==
-*The normal [[aortic valve]] has an orifice area of 4 cm2. [[Aortic stenosis]] is a progressive pathology that becomes usually symptomatic when the area decreases to 1 cm2. Once symptomatic, the most effective treatment for [[aortic stenosis]] is [[aortic valve replacement]].
-*Almost all symptomatic patients should undergo [[aortic valve replacement]]. One important exception is in the case of severe aortic stenosis with ventricle dysfunction where extensive testing should be done to differentiate between true severe aortic stenosis and pseudo-severe aortic stenosis. Patients with true severe [[low flow low gradient aortic stenosis]] benefit from [[aortic valve replacement]], whereas patients with pseudo-severe [[low flow low gradient aortic stenosis]] might not benefit from [[aortic valve replacement]] and have higher operative mortality.
+The general approach to treating Aortic Valve Stenosis has the following important aspects.<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=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. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }} </ref>
+*The normal [[aortic valve]] has an orifice area of 4 cm<sup>2</sup>. [[Aortic stenosis]] is a progressive pathology that becomes usually symptomatic when the area decreases to 1 cm<sup>2</sup>. Once symptomatic, the most effective treatment for [[aortic stenosis]] is [[aortic valve replacement]].  Almost all symptomatic patients should undergo [[aortic valve replacement]]. One important exception is in the case of severe aortic stenosis with ventricle dysfunction where extensive testing should be done to differentiate between true severe aortic stenosis and pseudo-severe aortic stenosis. Patients with true severe [[low flow low gradient aortic stenosis]] benefit from [[aortic valve replacement]], whereas patients with pseudo-severe [[low flow low gradient aortic stenosis]] might not benefit from [[aortic valve replacement]] and have higher operative mortality.
+*Asymptomatic patients should be followed up yearly for any new onset of symptoms. No treatment has been proven to delay the progression of aortic stenosis. Follow up with an echocardiography should be done every 1, 3, 5 years in severe, moderate and mild aortic stenosis respectively.<ref>{{Cite journal
+ | author = [[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]]
+ | title = Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics
+ | journal = [[Circulation]]
+ | volume = 108
+ | issue = 3
+ | pages = 319–324
+ | year = 2003
+ | month = July
+ | doi = 10.1161/01.CIR.0000079171.43055.46
+ | pmid = 12835219
+}}</ref>
 *Patients undergoing [[aortic valve replacement]] and having co-existing multi-vessel [[coronary artery disease]] should have concomitantly [[CABG]].<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>
-; Shown below is an algorithm showing the management of symptomatic and asymptomatic patients with aortic stenosis<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>.
+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>
-[[Image:Management_of_Aortic_Stenosis.png|center|600px|Management of patients with aortic stenosis]]
+<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>
 ====Available Therapeutic Options====
+Following are some of the available therapeutic options for Aortic Stenosis.<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=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. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }} </ref><ref name="pmid27012409">{{cite journal| author=Vahl TP, Kodali SK, Leon MB| title=Transcatheter Aortic Valve Replacement 2016: A Modern-Day "Through the Looking-Glass" Adventure. | journal=J Am Coll Cardiol | year= 2016 | volume= 67 | issue= 12 | pages= 1472-87 | pmid=27012409 | doi=10.1016/j.jacc.2015.12.059 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27012409  }} </ref>
 *[[Aortic stenosis surgery]] via [[aortic valve replacement]]
 *[[Transcatheter aortic valve implantation]]
 *[[Percutaneous aortic balloon valvotomy (PABV)]] or [[aortic valvuloplasty]]
 *Medical management
+==ESC/EACTS Guidelines==
+===Indications for Intervention in Aortic Stenosis and Recommendations for the Choice of Intervention Mode<ref name="BaumgartnerFalk2017">{{cite journal|last1=Baumgartner|first1=Helmut|last2=Falk|first2=Volkmar|last3=Bax|first3=Jeroen J|last4=De Bonis|first4=Michele|last5=Hamm|first5=Christian|last6=Holm|first6=Per Johan|last7=Iung|first7=Bernard|last8=Lancellotti|first8=Patrizio|last9=Lansac|first9=Emmanuel|last10=Rodriguez Muñoz|first10=Daniel|last11=Rosenhek|first11=Raphael|last12=Sjögren|first12=Johan|last13=Tornos Mas|first13=Pilar|last14=Vahanian|first14=Alec|last15=Walther|first15=Thomas|last16=Wendler|first16=Olaf|last17=Windecker|first17=Stephan|last18=Zamorano|first18=Jose Luis|last19=Roffi|first19=Marco|last20=Alfieri|first20=Ottavio|last21=Agewall|first21=Stefan|last22=Ahlsson|first22=Anders|last23=Barbato|first23=Emanuele|last24=Bueno|first24=Héctor|last25=Collet|first25=Jean-Philippe|last26=Coman|first26=Ioan Mircea|last27=Czerny|first27=Martin|last28=Delgado|first28=Victoria|last29=Fitzsimons|first29=Donna|last30=Folliguet|first30=Thierry|last31=Gaemperli|first31=Oliver|last32=Habib|first32=Gilbert|last33=Harringer|first33=Wolfgang|last34=Haude|first34=Michael|last35=Hindricks|first35=Gerhard|last36=Katus|first36=Hugo A|last37=Knuuti|first37=Juhani|last38=Kolh|first38=Philippe|last39=Leclercq|first39=Christophe|last40=McDonagh|first40=Theresa A|last41=Piepoli|first41=Massimo Francesco|last42=Pierard|first42=Luc A|last43=Ponikowski|first43=Piotr|last44=Rosano|first44=Giuseppe M C|last45=Ruschitzka|first45=Frank|last46=Shlyakhto|first46=Evgeny|last47=Simpson|first47=Iain A|last48=Sousa-Uva|first48=Miguel|last49=Stepinska|first49=Janina|last50=Tarantini|first50=Giuseppe|last51=Tchétché|first51=Didier|last52=Aboyans|first52=Victor|last53=Windecker|first53=Stephan|last54=Aboyans|first54=Victor|last55=Agewall|first55=Stefan|last56=Barbato|first56=Emanuele|last57=Bueno|first57=Héctor|last58=Coca|first58=Antonio|last59=Collet|first59=Jean-Philippe|last60=Coman|first60=Ioan Mircea|last61=Dean|first61=Veronica|last62=Delgado|first62=Victoria|last63=Fitzsimons|first63=Donna|last64=Gaemperli|first64=Oliver|last65=Hindricks|first65=Gerhard|last66=Iung|first66=Bernard|last67=Jüni|first67=Peter|last68=Katus|first68=Hugo A|last69=Knuuti|first69=Juhani|last70=Lancellotti|first70=Patrizio|last71=Leclercq|first71=Christophe|last72=McDonagh|first72=Theresa|last73=Piepoli|first73=Massimo Francesco|last74=Ponikowski|first74=Piotr|last75=Richter|first75=Dimitrios J|last76=Roffi|first76=Marco|last77=Shlyakhto|first77=Evgeny|last78=Simpson|first78=Iain A|last79=Zamorano|first79=Jose Luis|last80=Kzhdryan|first80=Hovhannes K|last81=Mascherbauer|first81=Julia|last82=Samadov|first82=Fuad|last83=Shumavets|first83=Vadim|last84=Camp|first84=Guy Van|last85=Lončar|first85=Daniela|last86=Lovric|first86=Daniel|last87=Georgiou|first87=Georgios M|last88=Linhartova|first88=Katerina|last89=Ihlemann|first89=Nikolaj|last90=Abdelhamid|first90=Magdy|last91=Pern|first91=Teele|last92=Turpeinen|first92=Anu|last93=Srbinovska-Kostovska|first93=Elizabeta|last94=Cohen|first94=Ariel|last95=Bakhutashvili|first95=Zviad|last96=Ince|first96=Hüseyin|last97=Vavuranakis|first97=Manolis|last98=Temesvári|first98=András|last99=Gudnason|first99=Thorarinn|last100=Mylotte|first100=Darren|last101=Kuperstein|first101=Rafael|last102=Indolfi|first102=Ciro|last103=Pya|first103=Yury|last104=Bajraktari|first104=Gani|last105=Kerimkulova|first105=Alina|last106=Rudzitis|first106=Ainars|last107=Mizariene|first107=Vaida|last108=Lebrun|first108=Frédéric|last109=Demarco|first109=Daniela Cassar|last110=Oukerraj|first110=Latifa|last111=Bouma|first111=Berto J|last112=Steigen|first112=Terje Kristian|last113=Komar|first113=Monika|last114=De Moura Branco|first114=Luisa Maria|last115=Popescu|first115=Bogdan A|last116=Uspenskiy|first116=Vladimir|last117=Foscoli|first117=Marina|last118=Jovovic|first118=Ljiljana|last119=Simkova|first119=Iveta|last120=Bunc|first120=Matjaz|last121=de Prada|first121=José Antonio Vázquez|last122=Stagmo|first122=Martin|last123=Kaufmann|first123=Beat Andreas|last124=Mahdhaoui|first124=Abdallah|last125=Bozkurt|first125=Engin|last126=Nesukay|first126=Elena|last127=Brecker|first127=Stephen J D|title=2017 ESC/EACTS Guidelines for the management of valvular heart disease|journal=European Heart Journal|volume=38|issue=36|year=2017|pages=2739–2791|issn=0195-668X|doi=10.1093/eurheartj/ehx391}}</ref>===
+<br />
+{| class="wikitable"
+|+
+!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)<ref name="pmid20961243">{{cite journal |vauthors=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 |title=Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery |journal=N. Engl. J. Med. |volume=363 |issue=17 |pages=1597–607 |date=October 2010 |pmid=20961243 |doi=10.1056/NEJMoa1008232 |url=}}</ref><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><ref name="pmid25442986">{{cite journal |vauthors=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 |title=Contemporary real-world outcomes of surgical aortic valve replacement in 141,905 low-risk, intermediate-risk, and high-risk patients |journal=Ann. Thorac. Surg. |volume=99 |issue=1 |pages=55–61 |date=January 2015 |pmid=25442986 |doi=10.1016/j.athoracsur.2014.06.050 |url=}}</ref> and valve area <1.0 cm² (or <0.6 cm²/m²)<ref name="“2021">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+! style="background:green; color:white" |I
+! style="background:blue; color:white" |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
+! style="background:green; color:white" |I
+! style="background:blue; color:white" |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
+! style="background:yellow" |IIa
+! style="background:indigo; color:white" |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
+! style="background:yellow" |IIa
+! style="background:indigo; color:white" |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
+! style="background:red; color:white" |III
+! style="background:indigo; color:white" |C
+|-
+! colspan="3" |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<ref name="“20212">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+! style="background:green; color:white" |I
+! style="background:indigo; color:white" |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<ref name="“20212" />
+! style="background:green; color:white" |I
+! style="background:indigo; color:white" |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<ref name="“20212" />
+! style="background:green; color:white" |I
+! style="background:blue; color:white" |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<ref name="pmid20961243">{{cite journal |vauthors=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 |title=Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery |journal=N. Engl. J. Med. |volume=363 |issue=17 |pages=1597–607 |date=October 2010 |pmid=20961243 |doi=10.1056/NEJMoa1008232 |url=}}</ref><ref name="pmid27050187">{{cite journal |vauthors=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 |title=3-Year Outcomes in High-Risk Patients Who Underwent Surgical or Transcatheter Aortic Valve Replacement |journal=J. Am. Coll. Cardiol. |volume=67 |issue=22 |pages=2565–74 |date=June 2016 |pmid=27050187 |doi=10.1016/j.jacc.2016.03.506 |url=}}</ref><ref name="“20212" />
+! style="background:green; color:white" |I
+! style="background:teal; color:white" |A
+|-
+|SAVR or TAVI are recommended for remaining patients according to individual clinical, anatomical, and procedural characteristics.<ref name="“20212" /> In patients who are at increased surgical risk (STS or EuroSCORE II ≥ 4% or logistic EuroSCORE I ≥ 10%<sup>b</sup> 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<ref name="pmid20961243">{{cite journal |vauthors=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 |title=Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery |journal=N. Engl. J. Med. |volume=363 |issue=17 |pages=1597–607 |date=October 2010 |pmid=20961243 |doi=10.1056/NEJMoa1008232 |url=}}</ref><ref name="pmid27050187">{{cite journal |vauthors=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 |title=3-Year Outcomes in High-Risk Patients Who Underwent Surgical or Transcatheter Aortic Valve Replacement |journal=J. Am. Coll. Cardiol. |volume=67 |issue=22 |pages=2565–74 |date=June 2016 |pmid=27050187 |doi=10.1016/j.jacc.2016.03.506 |url=}}</ref><ref name="pmid21639811">{{cite journal |vauthors=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 |title=Transcatheter versus surgical aortic-valve replacement in high-risk patients |journal=N. Engl. J. Med. |volume=364 |issue=23 |pages=2187–98 |date=June 2011 |pmid=21639811 |doi=10.1056/NEJMoa1103510 |url=}}</ref><ref name="pmid25788234">{{cite journal |vauthors=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 |title=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 |journal=Lancet |volume=385 |issue=9986 |pages=2477–84 |date=June 2015 |pmid=25788234 |doi=10.1016/S0140-6736(15)60308-7 |url=}}</ref><ref name="pmid24678937">{{cite journal |vauthors=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 |title=Transcatheter aortic-valve replacement with a self-expanding prosthesis |journal=N. Engl. J. Med. |volume=370 |issue=19 |pages=1790–8 |date=May 2014 |pmid=24678937 |doi=10.1056/NEJMoa1400590 |url=}}</ref><ref name="pmid30704298">{{cite journal |vauthors=Thyregod HGH, 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 |title=Five-Year Clinical and Echocardiographic Outcomes from the Nordic Aortic Valve Intervention (NOTION) Randomized Clinical Trial in Lower Surgical Risk Patients |journal=Circulation |volume= |issue= |pages= |date=February 2019 |pmid=30704298 |doi=10.1161/CIRCULATIONAHA.118.036606 |url=}}</ref><ref name="pmid27040324">{{cite journal |vauthors=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 |title=Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients |journal=N. Engl. J. Med. |volume=374 |issue=17 |pages=1609–20 |date=April 2016 |pmid=27040324 |doi=10.1056/NEJMoa1514616 |url=}}</ref><ref>{{Cite journal
+ | author = [[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]]
+ | title = Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis
+ | journal = [[Lancet (London, England)]]
+ | volume = 387
+ | issue = 10034
+ | pages = 2218–2225
+ | year = 2016
+ | month = May
+ | doi = 10.1016/S0140-6736(16)30073-3
+ | pmid = 27053442
+}}</ref><ref>{{Cite journal
+ | author = [[George C. M. Siontis]], [[Fabien Praz]], [[Thomas Pilgrim]], [[Dimitris Mavridis]], [[Subodh Verma]], [[Georgia Salanti]], [[Lars Sondergaard]], [[Peter Juni]] & [[Stephan Windecker]]
+ | title = Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of severe aortic stenosis: a meta-analysis of randomized trials
+ | journal = [[European heart journal]]
+ | volume = 37
+ | issue = 47
+ | pages = 3503–3512
+ | year = 2016
+ | month = December
+ | doi = 10.1093/eurheartj/ehw225
+ | pmid = 27389906
+}}</ref><ref>{{Cite journal
+ | author = [[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]]
+ | title = Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients
+ | journal = [[The New England journal of medicine]]
+ | volume = 376
+ | issue = 14
+ | pages = 1321–1331
+ | year = 2017
+ | month = April
+ | doi = 10.1056/NEJMoa1700456
+ | pmid = 28304219
+}}</ref>
+! style="background:green; color:white" |I
+! style="background:blue; color:white" |B
+|-
+|Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI<ref name="“20213">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+! style="background:orange; color:white" |IIb
+! style="background:indigo; color:white" |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<ref name="“20214">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+! style="background:orange; color:white" |IIb
+! style="background:indigo; color:white" |C
+|-
+! colspan="3" |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<ref name="“20215">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+! style="background:green; color:white" |I
+! style="background:blue; color:white" |B
+|-
+|Intervention is recommended in asymptomatic patients with severe aortic stenosis and demonstrable symptoms on exercise testing
+! style="background:green; color:white" |I
+! style="background:indigo; color:white" |C
+|-
+|Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without
+another cause<ref name="“20216">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+! style="background:yellow" |IIa
+! style="background:blue; color:white" |B
+|-
+|Intervention should be considered in asymptomatic patients with severe aortic stenosis and a sustained fall in BP (>20 mmHg) during exercise testing<ref name="“20217">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+! style="background:yellow" |IIa
+! style="background:indigo; color:white" |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:<ref name="“20219">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+*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
+! style="background:yellow" |IIa
+! style="background:blue; color:white" |B
+|-
+! colspan="3" |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<ref name="“20218">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+! style="background:green; color:white" |I
+! style="background:indigo; color:white" |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<ref name="“202110">{{cite web|url=https://academic.oup.com/eurheartj/article/43/7/561/6358470?login=false#341357950}}</ref>
+! style="background:yellow" |IIa
+! style="background:indigo; color:white" |C
+|-
+|}
+{| class="wikitable"
+|'''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
+*<sup>a</sup>In 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.
+*<sup>b</sup>STS 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.
+*<sup>c</sup>Moderate 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==
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+{{WH}}
+{{WS}}
+[[CME Category::Cardiology]]
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-[[Category:Signs and symptoms]]
-[[Category:Physical Examination]]
 [[Category:Valvular heart disease]]
 [[Category:Cardiology]]
 [[Category:Congenital heart disease]]
-[[Category:Mature chapter]]
 [[Category:Cardiac surgery]]
 [[Category:Surgery]]
-[[Category:Overview complete]]
-[[Category:For review]]
-[[Category:Template complete]]
-{{WH}}
-{{WS}}