p.26 抽出テキスト

The interplay between estimated life expectancy and prosthetic heart valve durability is a key consideration in these discussions. Age is a surrogate for life expectancy but had no impact on the outcomes of the low-risk RCTs at 12 year follow-up. Life expectancy varies widely across the world and is highly dependent on absolute age, sex, frailty, and the presence of comorbidities (http://ghdx.healthdata.org/ record/ihme-data/gbd-2017-life-tables-1950-2017); it may be a better guide than age alone but is difficult to determine in individual patients.

Recommendations on indications for interventiona in symptomatic (A) and asymptomatic (B) aortic stenosis and recommended mode of intervention (C)

A) Symptomatic aortic stenosis Classb Levelc

Intervention is recommended in symptomatic patients with severe, high-gradient aortic stenosis [mean gradient >_40 mmHg, peak velocity >_4.0 m/s, and valve area <_1.0 cm2 (or <_0.6 cm2/ m2)].235,236 I B Intervention is recommended in symptomatic patients with severe low-flow (SVi <_35 mL/m2), low-gradient (<40 mmHg) aortic stenosis with reduced ejection fraction (<50%), and evidence of flow (contractile) reserve.32,237 I B Intervention should be considered in symptomatic patients with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction after careful confirmation that the aortic stenosis is severed (Figure 3). IIa C Intervention should be considered in symptomatic patients with low-flow, low-gradient severe aortic stenosis and reduced ejection fraction without flow (contractile) reserve, particularly when CCT calcium scoring confirms severe aortic stenosis. IIa C Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year. III C B) Asymptomatic patients with severe aortic stenosis Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <50%) without another cause.9,238,239 I B Intervention is recommended in asymptomatic patients with severe aortic stenosis and demonstrable symptoms on exercise testing. I C Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause.9,240,241 IIa B Intervention should be considered in asymptomatic patients with severe aortic stenosis and a sustained fall in BP (>20 mmHg) during exercise testing. IIa C

Continued ............................................................................................................................................................................ Intervention should be considered in asympto-

matic patients with LVEF >55% and a normal exercise test if the procedural risk is low and one of the following parameters is present: • Very severe aortic stenosis (mean gradient

>_60 mmHg or Vmax >5 m/s).9,242

• Severe valve calcification (ideally assessed by

CCT) and Vmax progression >_0.3 m/s/ year.164,189,243

• Markedly elevated BNP levels (>3 age- and

sex-corrected normal range) confirmed by repeated measurements and without other explanation.163,171 IIa B C) Mode of intervention Aortic valve interventions must be performed in Heart Valve Centres that declare their local expertise and outcomes data, have active interventional cardiology and cardiac surgical programmes on site, and a structured collaborative Heart Team approach. I C The choice between surgical and transcatheter intervention must be based upon careful evaluation of clinical, anatomical, and procedural factors by the Heart Team, weighing the risks and benefits of each approach for an individual patient. The Heart Team recommendation should be discussed with the patient who can then make an informed treatment choice. I C SAVR is recommended in younger patients who are low risk for surgery (<75 yearse and STS- PROM/EuroSCORE II <4%)e,f, or in patients who are operable and unsuitable for transfemoral TAVI.244 I B TAVI is recommended in older patients (>_75 years), or in those who are high risk (STS- PROM/EuroSCORE IIf >8%) or unsuitable for surgery.197206,245 I A SAVR or TAVI are recommended for remaining patients according to individual clinical, anatomical, and procedural characteristics.202205,207,209,210,212 f,g I B Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI. IIb C Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in haemodynamically unstable patients and (if feasible) in those with severe aortic stenosis who require urgent highrisk NCS (Figure 11). IIb C D) Concomitant aortic valve surgery at the time of other cardiac/ascending aorta surgery SAVR is recommended in patients with severe aortic stenosis undergoing CABG or surgical intervention on the ascending aorta or another valve. I C

Continued Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026