Aortic Stenosis

Obtain transthoracic echocardiography (TTE) as the first-line imaging study. Concordant severe AS is supported by aortic valve area (AVA) less than 1.0 cm² with peak aortic jet velocity (Vmax) at least 4.0 m/s or mean transvalvular gradient at least 40 mm Hg; concordant nonsevere AS is supported by AVA greater than 1.0 cm² with mean gradient below 40 mm Hg or Vmax below 4.0 m/s.jacc+2jaccDiagnostic Value of Aortic Valve Calcification Levels in the Assessment of Low-Gradient Aortic StenosisjaccAdjudication of Low-Flow, Low-Gradient Aortic Stenosis Severity: Dobutamine Stress Echocardiography and MSCT Are Complementary, Not CompetitivejaccConfirmation of Aortic Stenosis Severity in Case of Discordance Between Aortic Valve Area and Gradient

Do not base severity on auscultation alone. When AVA, Vmax, and mean gradient disagree, first verify acquisition and continuity-equation inputs, particularly LVOT measurement and pulsed-wave versus continuous-wave Doppler placement. Then integrate stroke volume, LVEF, LV hypertrophy, symptoms, valve calcification, and dimensionless index; a dimensionless index of 0.25 or less supports severe stenosis.jacc+1jaccNormal-Flow Low-Gradient Aortic Stenosis: Comparing the U.S. and European GuidelinesOxford AcademicEchocardiographic assessment of valve stenosis: EAE/ASE ...

Classify discordance by flow and LVEF because the next test differs. Low flow is generally identified by stroke-volume index below 35 mL/beat/m²; low-flow, low-gradient AS may occur with reduced LVEF (classical) or preserved LVEF (paradoxical).jaccjaccNormal-Flow Low-Gradient Aortic Stenosis: Comparing the U.S. and European Guidelines

In low-flow discordant AS, dobutamine stress echocardiography (DSE) can increase transvalvular flow and reconcile AVA with gradient; it is considered the reference functional test for severity grading in low-flow states. Use caution in advanced cardiomyopathy because dobutamine may provoke or worsen arrhythmias and mitral regurgitation.jaccjaccDiagnostic Value of Aortic Valve Calcification Levels in the Assessment of Low-Gradient Aortic Stenosis

A stress AVA below 1.0 cm² has been used to define true severe AS, but DSE may be nondiagnostic when flow reserve is absent or limited; one analysis cited a nondiagnostic rate of approximately 55% in classical low-flow, low-gradient AS. In that setting, noncontrast ECG-gated multislice CT aortic valve calcium scoring provides an anatomic adjudication strategy rather than repeating an indeterminate stress study.jaccjaccAdjudication of Low-Flow, Low-Gradient Aortic Stenosis Severity: Dobutamine Stress Echocardiography and MSCT Are Complementary, Not Competitive

For CT calcium scoring, thresholds supporting severe AS are 2,000 Agatston units in men and 1,200 Agatston units in women. When annular size is unusually small or large, index calcium burden to annular area; reported severe thresholds are 500 AU/cm² in men and 300 AU/cm² in women.jaccjaccConfirmation of Aortic Stenosis Severity in Case of Discordance Between Aortic Valve Area and Gradient

CT calcium burden is not a substitute for careful Doppler review. It should resolve a clinically meaningful uncertainty—whether a patient with symptoms, ventricular dysfunction, or another potential intervention indication truly has severe AS—because valve replacement for low-gradient disease depends on confirmation of severe obstruction.jacc+1jaccAdjudication of Low-Flow, Low-Gradient Aortic Stenosis Severity: Dobutamine Stress Echocardiography and MSCT Are Complementary, Not CompetitivejaccConfirmation of Aortic Stenosis Severity in Case of Discordance Between Aortic Valve Area and Gradient

Once severe AS is confirmed and valve replacement is under consideration, use a multidisciplinary Heart Team to select TAVR versus SAVR. The TAVR device evaluation must address annular fit, vascular access, coronary anatomy, calcification distribution, concurrent cardiac disease, and the patient’s ability to receive antithrombotic therapy.accessdata fda+1accessdata fdaTranscatheter Aortic Valve ReplacementScienceDirectSurgical vs transcatheter aortic valve replacement in bicuspid aortic valve stenosis: A systematic review and meta-analysis - ScienceDirect

Transfemoral TAVR was compared with surgery in low-surgical-risk severe AS in a randomized trial, establishing that TAVR is an evidence-based replacement option in appropriately selected low-risk patients.NEJMNEJMTranscatheter Aortic-Valve Replacement with a Balloon- ... TAVR also became a treatment option for patients unsuitable for surgery.NEJMNEJMTranscatheter Aortic-Valve Replacement for Inoperable ... Procedure selection should nevertheless account for access feasibility and anatomic hazards rather than operative-risk category alone.accessdata fda+1accessdata fdaTranscatheter Aortic Valve ReplacementScienceDirectSurgical vs transcatheter aortic valve replacement in bicuspid aortic valve stenosis: A systematic review and meta-analysis - ScienceDirect

SAVR should be favored when associated pathology requires an open surgical approach, including aortic root dilatation, complex coronary disease, or severe mitral regurgitation in the setting of bicuspid AS.ScienceDirectScienceDirectSurgical vs transcatheter aortic valve replacement in bicuspid aortic valve stenosis: A systematic review and meta-analysis - ScienceDirect For bicuspid anatomy, randomized comparisons of TAVR and SAVR are lacking; observational and propensity-matched data may inform counseling but do not replace anatomy-based surgical assessment.ScienceDirect+2ScienceDirectTemporal Trends and Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement for Bicuspid Aortic Valve Stenosis - ScienceDirectScienceDirectPropensity-Matched Outcomes Comparing TAVR in Bicuspid vs Surgery in Tricuspid Aortic Valve Stenosis - ScienceDirectScienceDirectSurgical vs transcatheter aortic valve replacement in bicuspid aortic valve stenosis: A systematic review and meta-analysis - ScienceDirect

Before TAVR, identify device-specific contraindications and access barriers. The SAPIEN 3 labeling excludes patients unable to tolerate antithrombotic medication or with active infection; it also identifies unsuitable annular sizing, heavily diseased or undersized femoral arteries, abnormal access vessels, and large leaflet calcium that could obstruct coronary arteries as procedural concerns.accessdata fdaaccessdata fdaTranscatheter Aortic Valve Replacement

For patients in whom TTE confirms nonsevere AS or severity remains unconfirmed after adjudication, continue guideline-directed echocardiographic follow-up rather than referring directly for valve replacement.AHA Journals+1AHA Journals2020 ACC/AHA Guideline for the Management of Patients ...jaccAdjudication of Low-Flow, Low-Gradient Aortic Stenosis Severity: Dobutamine Stress Echocardiography and MSCT Are Complementary, Not Competitive Reassess symptoms, ventricular function, Doppler severity, and the development of a discordant low-flow pattern at each clinical change; new uncertainty should trigger repeat integrated TTE and targeted DSE or CT calcium scoring rather than presuming progression.AHA Journals+2AHA Journals2020 ACC/AHA Guideline for the Management of Patients ...jaccDiagnostic Value of Aortic Valve Calcification Levels in the Assessment of Low-Gradient Aortic StenosisjaccNormal-Flow Low-Gradient Aortic Stenosis: Comparing the U.S. and European Guidelines

Balloon aortic valvuloplasty (BAV) is a palliative procedure for selected elderly patients with symptomatic AS and is not a durable alternative to valve replacement.NEJM+1NEJMBalloon Aortic Valvuloplasty in 170 Consecutive PatientsNEJMPredictors of Event-Free Survival after Balloon Aortic ... Use it only when a temporary reduction in obstruction has a defined clinical objective, such as palliation or a bridge while candidacy for definitive treatment is clarified; reassess for recurrent limitation and definitive-valve options after the procedure.NEJM+1NEJMBalloon Aortic Valvuloplasty in 170 Consecutive PatientsNEJMPredictors of Event-Free Survival after Balloon Aortic ...