Table 1

Indications for aortic valve intervention in MAVD according to European guidelines

Mild ARModerate ARSevere AR
Mild AS Mild/moderate MAVD
No indication for AV Intervention 		Moderate MAVD
No indication for AV Intervention 		Severe MAVD
AV Intervention (class I) if:

  • Symptoms, LVEF ≤50%, and/or undergoing other cardiac surgery.

AV Intervention (Class IIa) if:

  • Asymptomatic, LVEF >50% and LVESD ≥50 mm.

Moderate AS Moderate MAVD
No indication for AV Intervention 		Likely severe MAVD*
AV intervention (Class I) if:

  • High gradient.

  • Symptoms, LVEF ≤50%, and/or undergoing other cardiac surgery.

AV intervention (class IIa) if:

  • Low gradient.

  • Symptoms, LVEF ≤50%, and/or LVESD ≥50 mm.

  • Confirmation of AV disease severity by DSE or MDCT.

 Severe MAVD
AV intervention (class I) if:

  • Symptoms, LVEF ≤50%, and/or undergoing other cardiac surgery.

AV intervention (class IIa) if:

  • Asymptomatic, LVEF >50% and LVESD ≥50 mm.

Severe AS Severe MAVD
AV intervention (class I) if:

  • High gradient.

  • Symptoms, LVEF <50% and/or undergoing other cardiac surgery.

AV intervention (class IIa) if:

  • Low flow, low gradient.

  • Symptoms and/or LVEF <50%.

  • Confirmation of severe AS by DSE or MDCT.

AV intervention (class IIa) if:

  • High gradient.

  • Asymptomatic and LVEF ≥50%.

  • Low surgical risk.

 Severe MAVD
AV intervention (class I) if:

  • High gradient.

  • Symptoms, LVEF <50% and/or undergoing other cardiac surgery.

AV intervention (class IIa) if:

  • Low flow, low gradient.

  • Symptoms and/or LVEF <50%.

  • Confirmation of severe AS by DSE or MDCT.

AV intervention (class IIa) if:

  • High gradient.

  • Asymptomatic and LVEF ≥50%.

  • Low surgical risk.

 Severe MAVD
AV intervention (class I) if:

  • Symptoms, LVEF ≤50% and/or undergoing other cardiac surgery.

AV intervention (class IIa) if:

  • Asymptomatic, LVEF >50% and LVESD ≥50 mm.

  • Low surgical risk.

  • *There is little detail in the guidelines for the MAVD category of moderate AS+moderate AR. However, the ESC guidelines suggest to consider these patients as having severe MAVD and assess the repercussions of the disease on symptomatic status and LV function. AV intervention refers to surgical aortic valve replacement, surgical aortic valve repair or transcatheter aortic valve replacement.

  • AR, aortic regurgitation; AS, aortic stenosis; AV, aortic valve; DSE, dobutamine-stress echocardiography; LV, left ventricle; LVESD, LV end-systolic diameter; LVEF, LV ejection fraction; MAVD, mixed aortic valve disease; MDCT, multidetector CT.