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Media Gallery

Stenotic aortic valve (macroscopic appearance).

of 1

Table 1. Common Causes of Aortic Stenosis Among Patients Requiring Surgery

Age < 70 years (n=324)

Age >70 years (n=322)

Bicuspid AV (50%)

Postinflammatory (25%)

Degenerative (18%)

Unicommissural (3%)

Hypoplastic (2%)

Indeterminate (2%)

Degenerative (48%)

Bicuspid (27%)

Postinflammatory (23%)

Hypoplastic (2%)

Table 2. Criteria for Determining Severity of Aortic Stenosis

Severity	Mean gradient (mmHg)	Aortic valve area (cm²)
Mild	< 25	>1.5
Moderate	25-40	1-1.5
Severe	>40	< 1 (or < 0.5 cm²/m² body surface area)
Critical	>80	< 0.5

Table 3. Indications for Aortic Valve Replacement in Aortic Stenosis

Indication	Class
Symptomatic severe high-gradient AS (Stage D1)	I
Asymptomatic severe AS (Stage C2) with and LVEF < 50%	I
Severe AS (Stage C or D) undergoing other cardiac surgery	I
Asymptomatic, very severe AS (Stage C1, aortic velocity ≥5.0 m/s) and low surgical risk	IIa
Asymptomatic, severe AS (Stage C1) and decreased expercise tolerance or an exercise fall in blood pressure	IIa
Symptomatic severe low flow/low gradient AS with reduced LVEF (Stage D2) with a low-dose dobutamine stress study with aortic velocity ≥4.0 m/s with a value are ≤1.0 cm²at any dobutamine dose	IIa
Symptomatic severe low flow/low gradient AS (Stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic and anatomic data support valve obstruction as the most likely cause of symptoms	IIa
Moderate AS (Stage B) who are undergoing other cardiac surgery	IIa
Asymptomatic severe AS (Stage C1) with rapid disease progression and low surgical risk	IIb

Table 4. Guideline Recommendations for Aortic Stenosis Intervention

Intervention Selection	AHA/ACC (2014)^[6]	ESC/EACTS (2012)^[5]	STS(2013)^[56]
Surgical AVR in patients with low or intermediate surgical risk	Class I	Class I
Transcatheter aortic valve replacement (TAVR) for patients who have a prohibitive surgical risk and a predicted post-TAVR survival >12 mo	Class I	Class I	Class I
TAVR for patients who have high surgical risk	Class IIa-Reasonable	Class IIa-Reasonable
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS	Class III	Class III
Balloon aortic valvuloplasty (BAV) as a bridge to surgical AVR or TAVR in severely symptomatic patients	Class IIb-Consider	Class IIb-Consider	Class IIa-Reasonable
BAV as bridge to AVR in hemodynamically unstable patients with severe AS where immediate AVR is not feasible		Class IIb-Consider	Class IIa-Reasonable
BAV in severely symptomatic patients where AVR is not an option for symptom relief			Class IIb-Consider
BAV as a palliative measure when surgery is contraindicated because of severe comorbidities		Class IIb-Consider	Class IIb-Consider

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Author

Xiushui (Mike) Ren, MD Cardiologist, The Permanente Medical Group; Associate Director of Research, Cardiovascular Diseases Fellowship, California Pacific Medical Center

Xiushui (Mike) Ren, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Society of Echocardiography

Disclosure: Nothing to disclose.

Chief Editor

Terrence X O'Brien, MD, MS, FACC Professor of Medicine/Cardiology, Director, Clinical Cardiovascular Research, Medical University of South Carolina College of Medicine; Director, Echocardiography Laboratory, Veterans Affairs Medical Center of Charleston

Terrence X O'Brien, MD, MS, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Jerry Balentine, DO Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine