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Table 3 Continued New or Revised Recommendations in 2017 version Class Recommendations in 2021 version Class Revised SAVR should be considered in asymptomatic patients with normal ejection fraction and none of the above-mentioned exercise test abnormalities if the surgical risk is low and one of the following findings is present: • Very severe aortic stenosis defined by a Vmax >5.5 m/s. • Severe valve calcification and a rate of Vmax progression >_0.3 m/s/year. • Markedly elevated BNP levels (>3x age- and sex-corrected normal range) confirmed by repeated measurements without other explanations. • Severe pulmonary hypertension (systolic pul- monary artery pressure at rest >60 mmHg confirmed by invasive measurement) without other explanation. IIa Intervention should be considered in asymptomatic patients with LVEF >55% and a normal exer- cise 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). • Severe valve calcification (ideally assessed by CCT) and Vmax progression >_0.3 m/s/year. • Markedly elevated BNP levels (>3 age- and sex-corrected normal range) confirmed by repeated measurements and without other explanation. IIa Section 5. Recommended mode of intervention In patients with aortic stenosis Revised The choice for intervention must be based on careful individual evaluation of technical suitability and weighing of risks and benefits of each modality. In addition, the local expertise and outcomes data for the given intervention must be taken into account. I 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 Revised SAVR is recommended in patients at low surgical risk (STS or EuroSCORE II <4% or logistic EuroSCORE I <10%, and no other risk factors not included in these scores, such as frailty, porcelain aorta, sequelae of chest radiation). I SAVR is recommended in younger patients who are low risk for surgery (<75 years and STS- PROM/ EuroSCORE II <4%) or in patients who are operable and unsuitable for transfemoral TAVI. I Revised TAVI is recommended in patients who are not suitable for SAVR as assessed by the Heart Team. I TAVI is recommended in older patients (>_75 years), or in those who are high-risk (STS-PROM/ EuroSCORE II >8%) or unsuitable for surgery. I Revised In patients who are at increased surgical risk (STS or EuroSCORE II >_4% or logistic EuroSCORE I >_10%, or other risk factors not included in these scores such as frailty, porcelain aorta, sequelae of chest radiation), the decision between SAVR and TAVI should be made by the Heart Team according to the individual patient characteristics, with TAVI being favoured in elderly patients suitable for transfemoral access. I SAVR or TAVI are recommended for remaining patients according to individual clinical, anatomical and procedural characteristics. I New Non-transfemoral TAVI may be considered in patients who are inoperable for SAVR and unsuitable for transfemoral TAVI. IIb Section 6. Indications for intervention in severe primary mitral regurgitation Revised Surgery is indicated in asymptomatic patients with LV dysfunction (LVESD>_45 mm and/or LVEF<_60%). I Surgery is recommended in asymptomatic patients with LV dysfunction (LVESD >_40 mm and/or LVEF <_60%). I Continued Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026