Aortic Stenosis Valve Replacement Guidelines

Primary Indications for Aortic Valve Replacement

The European Society of Cardiology recommends aortic valve replacement in all patients with severe aortic stenosis who have symptoms related to AS, left ventricular dysfunction, or abnormal exercise test showing symptoms clearly related to AS, regardless of surgical risk 1
The American College of Cardiology recommends valve replacement for symptomatic severe AS, with any symptoms related to AS warranting intervention 1, 2
Aortic valve replacement is indicated for severe AS with left ventricular dysfunction (LVEF <50%) not due to another cause, as recommended by the European Society of Cardiology and the American College of Cardiology 1, 3
The European Society of Cardiology and the American College of Cardiology recommend aortic valve replacement for severe AS in patients undergoing other cardiac surgery, such as CABG, ascending aorta surgery, or another valve surgery 1, 2
Asymptomatic severe AS with abnormal exercise test showing symptoms clearly related to AS is an indication for aortic valve replacement, according to the European Society of Cardiology 1

The European Society of Cardiology recommends aortic valve replacement for asymptomatic severe AS with abnormal exercise test showing fall in blood pressure below baseline 1
Moderate AS in patients undergoing other cardiac surgery is a secondary indication for aortic valve replacement, as recommended by the European Society of Cardiology 1
Symptomatic low-flow, low-gradient AS with normal EF after careful confirmation of severe AS is a secondary indication for aortic valve replacement, according to the European Society of Cardiology 1
The American College of Cardiology recommends aortic valve replacement for symptomatic low-flow, low-gradient AS with reduced EF and evidence of flow reserve on dobutamine stress echocardiography 1, 4

High-gradient severe AS is defined by AVA ≤1.0 cm² with peak velocity ≥4 m/s or mean gradient ≥40 mmHg, as recommended by the American College of Cardiology 4
Low-flow, low-gradient severe AS is defined by AVA ≤1.0 cm² with peak velocity <4 m/s or mean gradient <40 mmHg, according to the American College of Cardiology 4
Very severe AS is defined by peak velocity ≥5 m/s or mean gradient ≥60 mmHg, as recommended by the American College of Cardiology 3
Extremely severe AS is defined by AVA ≤0.6 cm², mean gradient ≥50 mmHg, or jet velocity ≥5 m/s, according to the American College of Cardiology 7

The American College of Cardiology recommends TAVR for patients with severe, symptomatic AS with prohibitive surgical risk (≥50% risk of mortality/morbidity at 30 days) 2
TAVR is a reasonable alternative to surgical AVR in patients at high surgical risk (STS score ≥8%), as recommended by the American College of Cardiology 2
The American College of Cardiology emphasizes the importance of a Heart Team approach in determining the optimal intervention strategy based on individual risk profile and anatomic suitability 7

Regular clinical evaluation every 6-12 months is recommended for asymptomatic severe AS, as suggested by the European Society of Cardiology 1
Serial echocardiography is recommended to monitor for disease progression in asymptomatic severe AS, according to the European Society of Cardiology 1
Exercise testing is recommended to unmask symptoms or abnormal hemodynamic responses in asymptomatic severe AS, as suggested by the American College of Cardiology 4
Earlier intervention should be considered in patients with rapid progression (velocity increase >0.3 m/s/year) or very severe AS, as recommended by the American College of Cardiology 5, 6