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Both the European Society of Cardiology (ESC) and American Heart Association/American College of Cardiology (AHA/ACC) guidelines for management of adults with valvular heart disease have been updated this year in response to publication of new evidence justifying revised or new recommendations.1 2 In particular, more detailed guidance is provided for choice of valve prosthesis type and implantation mode in patients with severe valvular aortic stenosis (AS).
Steps in decision making
There are three distinct steps in decision making in adults with severe AS:
Step 1: assess AS severity, symptom status, left ventricular (LV) function and comorbid conditions to determine if the patient has an indication for aortic valve replacement (AVR).
Step 2: consider the risk–benefit balance of a mechanical versus a bioprosthetic valve based on anticoagulation and bleeding risk considerations, the risk of structural valve deterioration and redo surgery and expected patient longevity.
Step 3: if a bioprosthetic valve is preferred, consider whether transcatheter valve implantation (TAVI) or surgical AVR (SAVR) is more appropriate for this patent.
Assessment of AS severity
Both guidelines acknowledge the complexity of AS assessment, emphasising that the current definition of severe AS includes:
high gradient severe AS (velocity 4 m/s or higher, mean gradient 40 mm Hg or higher)
low-flow low-gradient severe AS (velocity <4 m/s, mean gradient <40 mm Hg but valve area <1.0 cm2), with a low LV ejection fraction (EF)
low-flow low-gradient severe AS with a normal LV EF.
In patients with severe AS and a high velocity/gradient, valve area usually is 1.0 cm2 or less, but this is not required for diagnosis in either guideline as long as a reversible high flow state has been excluded. Low-flow in this context is defined as a stroke volume index 35 mL/m2 or less. When LV EF is low (<0.50), severe AS is defined as an aortic velocity ≥4 m/s, without an increase …
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