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......... valve interventions should be performed only in centres having both interventional cardiology and cardiac surgery services on site and a structured collaborative Heart Team approach. Balloon aortic valvuloplasty may be considered in highly symptomatic patients with AHF (i.e. cardiogenic shock) as bridge to TAVI or SAVR, or in advanced HF as BTR or DT.

Management of patients with heart failure and suspected severe low-flow low-gradient ASa

Dobutamine echo LVEF < 50%

OR TAVI (Class I)

SAVR (Class I)

Y N

Flow reservec Clinical and echo criteriab

High calcium scored

by CT

Y

Severe low-flow low-gradient AS N

Medical therapy

optimization

(Class I) Heart Teamg

(Class I) Heart Teamg

(Class I) Follow-up

Y

f N

e

Y f

OR TAVI (Class IIa)

SAVR (Class IIa)

N Y Y

Figure 16 Management of patients with severe low-flow low-gradient aortic stenosis and heart failure. AS= aortic stenosis; CT = computed tomography; EuroSCORE II= European System for Cardiac Operative Risk Evaluation II; LVEF= left ventricular ejection fraction; OMT = optimal medical therapy; SAVR= surgical aortic valve replacement; STS-PROM = Society of Thoracic Surgeons Predicted Risk of Mortality; TAVI= transcatheter aortic valve implantation. aValve area <_1 cm2, peak velocity <4.0 m/s, mean gradient <40; stroke volume index <_35 mL/m2. bAge >70 years, typical symptoms without other explanations, left ventricular hypertrophy or reduced left ventricular longitudinal function, mean gradient 3040 mmHg, valve area <_0.8 cm2, stroke volume index <_35 mL/m2 assessed by techniques other than standard Doppler. cFlow reserve is defined as stroke volume index increase >20%. dAS is very likely if calcium score is >_3000 in men and >_1600 in women. AS is likely if calcium score is >_2000 in men and >_1200 in women. AS is unlikely if calcium score is <1600 in men and <800 in women. eIncrease in valve area to >1.0 cm2 in response to flow increase (flow reserve) during dobutamine echo. fIncrease in mean gradient to at least 40 mmHg without significant change in valve area in response to flow increase (flow reserve) during dobutamine echo. gSAVR is recommended in patients aged <75 years and low surgical risk (STS-PROM score or EuroSCORE II <4%), whereas TAVI in those aged >75 years or at high/prohibitive surgical risk (STS-PROM score or EuroSCORE II >8%). In all the other cases, the choice between TAVI and SAVR is recommended to be decided by the Heart Team, weighing the pros and cons of each procedure, according to age, life expectancy, individual patient preference and features including clinical and anatomical aspects. Colour code for classes of recommendation: Green for Class of recommendation I; Yellow for Class of recommendation IIa (see Table 1 for further details on classes of recommendation). Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026