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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e95 CLINICAL STATEMENTS AND GUIDELINES

Recommendation-Specific Supportive Text

1.	 In symptomatic patients with severe high-gradient AS (Stage D1), ample evidence demonstrates the beneficial effects of AVR on survival, symptoms, and LV systolic function.35,41–46 The most common initial symptom of AS is exertional dyspnea or decreased exercise tolerance. Clinical vigilance is needed to recognize these early symptoms and proceed promptly to AVR. More severe “classical” symptoms of AS, including HF, syncope, or angina, can be avoided by appropriate treatment at the onset of even mild symptoms. Outcomes after surgical or transcatheter AVR are excellent in patients who do not have a high procedural risk.41,43–45 Surgical series demonstrate improved symptoms after AVR, and most patients have an improvement in exercise tolerance, as documented in studies with pre- and post-AVR exercise stress testing.41,43–46 Historical observation studies on outcomes in symptomatic patients with severe AS have been confirmed in RCTs comparing TAVI with palliative care in patients with a prohibitive surgical risk. The choice of surgical versus transcatheter AVR for patients with an indication for AVR is discussed in Section 3.2.4.1–3,5,6,12–16,35,42,47–55

2.	 In asymptomatic patients with severe AS and normal LV systolic function, the survival rate during the asymptomatic phase is similar to that of age-matched controls, with a low risk of sudden death (<1% per year) when patients are followed prospectively and when patients promptly report symptom onset. However, in patients with a low LVEF and severe AS, survival is better in those who undergo AVR than in those treated medically. The depressed LVEF in many patients is caused by excessive afterload (afterload mismatch), and LV function improves after AVR in such patients. If LV dysfunction is not caused

Figure 2. Timing of intervention for AS. Colors correspond to Table 2. Arrows show the decision pathways that result in a recommendation for AVR. Periodic monitoring is indicated for all patients in whom AVR is not yet indicated, including those with asymptomatic (Stage C) and symptomatic (Stage D) AS and those with low-gradient AS (Stage D2 or D3) who do not meet the criteria for intervention. See Section 3.2.4 for choice of valve type (mechanical versus bioprosthetic [TAVI or SAVR]) when AVR is indicated. AS indicates aortic stenosis; AVA, aortic valve area; AVAi, aortic valve area index; AVR, aortic valve replacement; BNP, B-type natriuretic peptide; BP, blood pressure; DSE, dobutamine stress echocardiography ETT, exercise treadmill test; LVEF, left ventricular ejection fraction; ∆Pmean, mean systolic pressure gradient between LV and aorta; SAVR, surgical aortic valve replacement; SVI, stroke volume index; TAVI, transcatheter aortic valve implantation; TAVR, transcatheter aortic valve replacement; and Vmax, maximum velocity.

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