Indications for valve replacement in aortic stenosis in adults
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
- Section Editors
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Edward Verrier, MD
Edward Verrier, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington School of Medicine
Surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) are the only effective treatments for severe aortic stenosis (AS). Recommendations for surgical valve replacement for AS are based upon comparisons of the natural history of patients with AS to outcomes after surgical aortic valve replacement (figure 1). Recommendations for TAVR for AS are based upon randomized trial and observational study data. (See "Natural history, epidemiology, and prognosis of aortic stenosis" and "Choice of prosthetic heart valve for surgical replacement" and "Transcatheter aortic valve replacement: Indications and outcomes".)
Indications for surgical AVR and TAVR for AS and choice of procedure are discussed here .
Other issues relating to the surgical AVR and TAVR, the medical management of patients with AS, and valve surgery in elderly adults are discussed separately. (See "Choice of prosthetic heart valve for surgical replacement" and "Transcatheter aortic valve replacement: Indications and outcomes" and "Medical management of asymptomatic aortic stenosis in adults" and "Medical management of symptomatic aortic stenosis" and "Valvular heart disease in elderly adults".)
APPROACH TO IDENTIFYING CANDIDATES FOR VALVE REPLACEMENT
The following are the key steps in determining whether a patient with aortic stenosis (AS) has an indication for valve replacement (algorithm 1):
●Identification of the patient’s symptom status
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- APPROACH TO IDENTIFYING CANDIDATES FOR VALVE REPLACEMENT
- Identification of patient's symptom status
- Identification of severe AS
- Assessment of left ventricular ejection fraction
- INDICATIONS FOR VALVE REPLACEMENT
- Symptomatic patients
- Asymptomatic severe aortic stenosis
- - Considerations
- - Left ventricular systolic dysfunction
- - Very severe AS
- - Role of exercise testing
- - Role of careful monitoring
- Low gradient aortic stenosis
- CHOICE OF SURGICAL OR TRANSCATHETER INTERVENTION
- Approach to choice of intervention for AS
- Choice of surgical valve replacement type
- CONCOMITANT CORONARY REVASCULARIZATION
- Candidates for aortic valve replacement who may require coronary revascularization
- - Coronary angiography prior to valve surgery
- Noninvasive coronary angiography
- - Revascularization and valve replacement
- Candidates for CABG who may require aortic valve replacement
- MEDICAL MANAGEMENT IN PATIENTS AWAITING SURGERY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS