The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

(aortic valve area less than 0.6 cm^2 , mean gradient
greater than 60 mm Hg, and jet velocity greater than
5.0 m per second) when the patient’s expected oper-
ative mortality is 1.0% or less. (Level of Evidence: C)
No ESC recommendation
5 ESC recommendation: AVR for severe AS with
excessive hypertrophy (≥15 mm), IIb (C)
6 ESC recommendation: AVR for AS with low gra-
dient (<40 mmHg) and LV dysfunction:
with contractile reserve, IIa (C)
without contractile reserve, IIb (C).

Class III
Aortic valve replacement is not useful for the pre-
vention of sudden death in asymptomatic patients
with AS who have none of the fi ndings listed under
the class IIa/IIb recommendations. (Level of Evi-
dence: B)

Aortic balloon valvotomy

Class IIb

1 Aortic balloon valvotomy might be reasonable as a

bridge to surgery in hemodynamically unstable adult

patients with AS who are at high risk for AVR. (Level

of Evidence: C) ESC recommendation, IIb (C)

2 Aortic balloon valvotomy might be reasonable for

palliation in adult patients with AS in whom AVR

cannot be performed because of serious comorbid

conditions. (Level of Evidence: C) No ESC

recommendation

3 ESC recommendation: Aortic balloon valvotomy

for patients with symptomatic severe AS who require

urgent major noncardiac surgery, IIb (C)

Class III

Aortic balloon valvotomy is not recommended as an

alternative to AVR in adult patients with AS; certain

Undergoing CABG

or other heart surgery?

Severe aortic stenosis

Vmax greater than 4 m/s

AVA less than 1.0 cm^2

Reevaluation

Symptoms?

Exercise test

Symptoms

hypotension

Yes Yes Equivocal No

Less than 0.50

Yes

No

Severe valve calcification,

rapid progression, and/or

expected delays in surgery

Clinical follow-up, patient education,

risk factor modification, annual echo

Normal

Normal

LV ejection fraction

Aortic valve replacement

Preoperative coronary angiography

Class I Class I Class IIb Class I Class IIb

Fig. 18.1 Management strategy for patients with severe aortic stenosis. Preoperative coronary angiography should be performed routinely
as determined by age, symptoms, and coronary risk factors. Cardiac catheterization and angiography may also be helpful when there is
discordance between clinical fi ndings and echocardiography.
AVA, aortic valve area; BP, blood pressure; CABG, coronary artery bypass graft surgery; LV, left ventricular; Vmax, maximal velocity across
aortic valve by Doppler echocardiography.