13
Figure 2. Indications for AVR in Patients With AS
Abnormal Aortic Valve With
Reduced Systolic Opening
Severe AS
Vmax ≥4 m/s
∆Pmean ≥40 mm Hg
Vmax 3–3.9 m/s
∆Pmean 20–39 mm Hg
Symptomatic
(stage D1)
LVEF <50%
(stage C2)
Other cardiac
surgery
Vmax ≥5 m/s
∆Pmean ≥60 mm Hg
Low surgical risk
Abnormal ETT
∆Vmax ≥0.3 m/s/y
Low surgical risk
AVR
(IIb)
AVR
(IIa)
AVR
(I)
Asymptomatic
(stage C)
Symptomatic
Asymptomatic
(stage B)
LVEF <50%
NO YES
DSE with AVA
≤1 cm
2
and
Vmax ≥4 m/s
(stage D2)
AVA ≤1 cm
2
and
LVEF ≥50%
(stage D3
a
)
Other
cardiac
surgery
AVR
(IIa)
Arrows show decision pathways that result in a recommendation for AVR. Periodic monitoring is
indicated for all patients in whom AVR is not yet indicated, including those with asymptomatic AS (stage
D or C) and those with low-gradient AS (stage D2 or D3) who do not meet the criteria for intervention.
a
AVR should be considered with stage D3 AS only if valve obstruction is the most likely cause of
symptoms, stroke volume index is <35 mL/m
2
, indexed AVA is ≤0.6 cm
2
/m
2
, and data are recorded
when the patient is normotensive (systolic BP <140 mm Hg ).
AS likely
cause of
symptoms
