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2017 Update Incorporated - Valvular Heart Disease

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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

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