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................................ 5.2 Indications for intervention (SAVR or TAVI) Indications for aortic valve intervention are summarized in the table of recommendations on indications for intervention in symptomatic and asymptomatic aortic stenosis and recommended mode of intervention and in Figure 4.

5.2.1 Symptomatic aortic stenosis Symptomatic severe aortic stenosis has dismal prognosis and early intervention is strongly recommended in all patients. The only exceptions are for those in whom intervention is unlikely to improve quality of life or survival (due to severe comorbidities) or for those with concomitant conditions associated with survival <1 year (e.g. malignancy) (section 3).

Intervention is recommended in symptomatic patients with highgradient aortic stenosis, regardless of LVEF. However, management of patients with low-gradient aortic stenosis is more challenging: • LV function usually improves after intervention in patients with low-flow, low-gradient aortic stenosis, when reduced ejection fraction is predominantly caused by excessive afterload.32,180

Management of patients with severe aortic stenosisa

Symptoms Y

N

LVEF < 50% Intervention likely to be of benefitb (after assessment of

comorbidity and frailty)

Physically active

Exercise test

Symptoms or sustained fall

in BP below baseline

Indicators of adverse prognosisd and low procedural risk Heart Team evaluationc

Educate patient and reassess in 6 months (or as soon as possible

if symptoms occur) Medical therapy

N

Y Y N

N

N

N Y Y

Y

Patients < 75 years at

low-risk for SAVR (STS-PROM/ EuroSCORE II < 4%)e OR Unsuitable for TF TAVI

and operable All other patients Patients ≥ 75 years

OR Unsuitable/High risk for SAVR (STS-PROM/ EuroSCORE II > 8%)e AND Suitable for TF TAVI

SAVRf SAVRf

or TAVIf TAVIf

Figure 4 Management of patients with severe aortic stenosis. BP= blood pressure; EuroSCORE = European System for Cardiac Operative Risk Evaluation; LVEF= left ventricular ejection fraction; SAVR= surgical aortic valve replacement; STS-PROM= Society of Thoracic Surgeons  predicted risk of mortality; TAVI = transcatheter aortic valve implantation; TF= transfemoral. aSee Figure 3: Integrated imaging assessment of aortic stenosis. bProhibitive risk is defined in Supplementary Table 5. cHeart Team assessment based upon careful evaluation of clinical, anatomical, and procedural factors (see Table 6 and table on Recommendations on indications for intervention in symptomatic and asymptomatic aortic stenosis and recommended mode of intervention). The Heart Team recommendation should be discussed with the patient who can then make an informed treatment choice. dAdverse features according to clinical, imaging (echocardiography/CT), and/or biomarker assessment. eSTS-PROM: http://riskcalc.sts.org/stswebriskcalc/#/calculate, EuroSCORE II: http://www.euroscore.org/calc.html. fIf suitable for procedure according to clinical, anatomical, and procedural factors (Table 6). Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026