Assessment of aortic valve disease - a clinician oriented review

Table 2 Indication for aortic valve replacement according to European Society of Cardiology/European Association for Cardio-Thoracic Surgery and American Heart Association/American College of Cardiology guidelines[33,34]

Criteria	Level of recommendation		Differences between guidelines
	ESC/EACTS	AHA/ACC
Severe AS with any symptoms clearly due to AS, based on history or unmasked by stress test	I	I	"High-gradient" in AHA/ACC guidelines
Asymptomatic severe AS with LVEF < 50%	I	I
Severe AS and another indication for surgery (CABG, thoracic aorta, another valve)	I	I
Asymptomatic severe AS where the systolic blood pressure does not increase by > 20 mmHg or drops compared with baseline during the treadmill test	IIa	IIa	AHA/ACC guidelines acknowledge the presence of fatigability during stress test as an indication for AVR
Moderate AS and another indication for surgery (CABG, thoracic aorta, another valve)	IIa	IIa
Low-flow/low-gradient/low-LVEF severe AS with proof of contractile reserve presence	IIa	IIa
Symptomatic low-flow/low-gradient/preserved LVEF severe AS after careful confirmation of severity	IIa	IIa
Truly asymptomatic severe AS (no symptoms during treadmill test, no risk criteria) with preserved LVEF if the surgical risk is deemed low and the following criteria are also satisfied: Very severe AS (maximal velocity ≥ 5.5 m/s); Severe valvular calcification and increased maximal velocity by ≥ 0.3 m/s per year	IIa	IIa for velocity ≥ 5 m/s (see text)	AHA/ACC guideline: Velocity ≥ 5 m/s or mean gradient ≥ 60 mmHg AND severe calcifications; velocity 4 to 4.9 m/s or mean gradient 40 to 59 mmHg AND severe valvular calcification AND stress test demonstrating reduced tolerance or drop in blood pressure
		IIb for maximal velocity increase by ≥ 0.3 m/s per year
Truly asymptomatic severe AS (no symptoms during treadmill test, no risk criteria) with preserved LVEF if the surgical risk is deemed low and 1 or more of the following criteria are also satisfied: Severely increased BNP/Nt-ProBNP levels at serial determinations and without an alternative explanation; increased transaortic pressure gradient at stress echocardiography by > 20 mmHg; excessive LV hypertrophy without an alternative explanation	IIb	-	This indication is not covered in the AHA/ACC guidelines
Low-flow/low-gradient/low-LVEF severe AS without contractile/flow reserve	IIb	-	This indication is not covered in the AHA/ACC guidelines

Class I: It is indicated, it is recommended; Class IIa: Should be considered, it is reasonable; Class IIb: May be considered; Class III: It is not indicated, it is contraindicated; ESC: European Society of Cardiology; EACTS: European Association for Cardio-Thoracic Surgery; AHA/ACC: American Heart Association/American College of Cardiology; AS: Aortic stenosis; LVEF: Left ventricular ejection fraction; CABG: Coronary artery bypass graft.