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............................................................................................................................................................................. Although some (now abandoned) surgical bioprosthetic designs have failed early, the durability of contemporary surgical bioprosthetic valves beyond 10 years is well established.220 Conversely, registry data provide some reassurance concerning the long-term durability of TAVI devices up to 8 years but largely relate to older high-/intermediate-risk patients,221224 whereas information concerning durability in low-risk patients is currently limited to 2-year follow-up. Data comparing the durability of transcatheter heart valves and surgical bioprostheses directly remain limited. Rates of aortic valve re-intervention were higher after TAVI using a balloon-expandable valve compared to SAVR at 5-year follow-up in the PARTNER 2A trial (3.2% vs. 0.8%; hazard ratio, 3.3; 95% CI, 1.38.1),206 whereas rates of structural valve deterioration (SVD) were not statistically different following SAVR and TAVI using the third generation SAPIEN 3 device in a parallel observational registry over the same time frame.225 Valve-in-valve TAVI is an established treatment option for surgical bioprosthetic valve deterioration but may not be appropriate or feasible in all patients due to the increased likelihood of PPM in patients with a small aortic root (or undersized original prosthesis), incompatible surgical valve designs associated with increased risk of coronary occlusion, or difficult vascular access; re-do SAVR should also be considered in these settings.226228 Favourable short-term outcomes of redo-TAVI have been demonstrated in selected older patients with transcatheter heart valve deterioration,229 despite theoretical concerns relating to maintained coronary access.230 A bicuspid aortic valve is more frequent in younger patients with aortic stenosis. While several registries have reported excellent outcomes of TAVI in patients with a bicuspid valve who were unsuitable for surgery,231233 SAVR remains more appropriate in patients with aortic stenosis affecting a bicuspid valve and in those with associated disease (e.g. aortic root dilatation, complex coronary disease, or severe mitral regurgitation) requiring a surgical approach. In summary, prosthetic heart valve durability is a key consideration in younger patients (<75 years) at low surgical risk and SAVR (if feasible) is therefore the preferred treatment option. Conversely, durability is a lower priority in older patients (>_75 years), or those who are inoperable or high risk for surgery, and TAVI is preferred in these groups (particularly if feasible via transfemoral approach). The Heart Team should make tailored recommendations for remaining patients based upon their individual characteristics (Table 6). This guidance should be re-addressed when further data concerning the long-term durability of TAVI become available. Balloon aortic valvuloplasty (BAV) may be considered as a bridge to TAVI or SAVR in patients with decompensated aortic stenosis and (when feasible) in those with severe aortic stenosis who require urgent high-risk non-cardiac surgery (NCS) (section 12). The procedure carries significant risk of complications234 and should only be undertaken after Heart Team discussion. 5.3 Medical therapy No medical therapies influence the natural history of aortic stenosis. Statins (which demonstrated favourable effects in pre-clinical studies) do not affect disease progression246 and clinical trials targeting calcium metabolic pathways are ongoing. Patients with heart failure who are unsuitable (or waiting) for SAVR or TAVI should be medically treated according to ESC heart failure Guidelines.247 ACEI are safe in aortic stenosis (provided that BP is monitored carefully) and may have beneficial myocardial effects before the onset of symptoms, and after TAVI and SAVR.248250 Coexisting hypertension should be treated to avoid additional afterload, although medication (particularly vasodilators) should be titrated to avoid symptomatic hypotension. Antithrombotic therapy after TAVI is discussed in section 11. 5.4 Serial testing Rate of progression of aortic stenosis varies widely. Asymptomatic patients, their family and medical carers need careful education, with emphasis on the importance of regular follow-up (ideally in a Heart Valve Clinic9) and prompt reporting of symptoms. Those with severe aortic stenosis should be followed up every 6 months (at least) to allow earliest symptom detection (using exercise testing if symptoms are doubtful) and any change in echocardiographic parameters (particularly LVEF). Measurement of natriuretic peptides may be considered. Several studies suggest that the prognosis of moderate degenerative aortic stenosis is worse than previously considered251254 (particularly if there is significant valve calcification) and these patients should be reevaluated at least annually. Younger patients with mild aortic stenosis and no significant calcification may be followed up every 23 years. 5.5 Special patient populations Women with aortic stenosis have higher mortality than men, resulting from late diagnosis and initial specialist assessment followed by less frequent and delayed referral for intervention.255257 Measures are needed to improve this situation and ensure that both sexes receive equivalent care. CAD and aortic stenosis frequently coexist and the combination confers higher risk of clinical events, therefore the need to consider revascularization in conjunction with aortic valve intervention is SAVR should be considered in patients with moderate aortic stenosish undergoing CABG or surgical intervention on the ascending aorta or another valve after Heart Team discussion. IIa C BNP = B-type natriuretic peptide; BP = blood pressure; CABG = coronary artery bypass grafting; CCT = cardiac computed tomography; EuroSCORE = European System for Cardiac Operative Risk Evaluation; LV = left ventricle/left ventricular; LVEF = left ventricular ejection fraction; NCS = non-cardiac surgery; SAVR = surgical aortic valve replacement; STS-PROM = Society of Thoracic Surgeons predicted risk of mortality; SVi = stroke volume index; TAVI = transcatheter aortic valve implantation; Vmax = peak transvalvular velocity. aSAVR or TAVI. bClass of recommendation. cLevel of evidence. dExplanations other than severe aortic stenosis for a small valve area but low gradient despite preserved LVEF are frequent and must be carefully excluded (Figure 3). eSTS-PROM: http://riskcalc.sts.org/stswebriskcalc/#/calculate, EuroSCORE II: http://www.euroscore.org/calc.html. fIf suitable for surgery (see Table 6). gIf suitable for transfemoral TAVI (see Table 6). hModerate aortic stenosis is defined as a valve area of 1.01.5 cm2 (or mean aortic gradient of 2540 mmHg) in normal flow conditions—clinical assessment is essential to determine whether SAVR is appropriate for an individual patient. 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