What are the indications for aortic valve replacement (AVR)?

From the Guidelines

Aortic valve replacement is indicated for symptomatic patients with severe aortic stenosis, as well as for asymptomatic patients with severe aortic stenosis and left ventricular dysfunction or other high-risk features, as outlined in the 2012 ACCF/AATS/SCAI/STS expert consensus document 1. The indications for aortic valve replacement can be broken down into several key categories:

• Symptomatic severe aortic stenosis, where symptoms such as angina, syncope, or heart failure are present 1
• Asymptomatic severe aortic stenosis with left ventricular dysfunction, defined as a left ventricular ejection fraction less than 50% 1
• Asymptomatic severe aortic stenosis with other high-risk features, such as a valve area less than 0.6 cm², a mean gradient greater than 60 mmHg, or rapid progression of stenosis 1
• Patients with severe aortic stenosis undergoing coronary artery bypass grafting, aortic surgery, or other valve surgery 1 The decision to perform aortic valve replacement should be based on a comprehensive evaluation of the patient's symptoms, left ventricular function, and other clinical factors, as well as the presence of any high-risk features. Some key points to consider when evaluating patients for aortic valve replacement include:
• The presence of symptoms, such as angina, syncope, or heart failure, which are indicative of severe aortic stenosis 1
• The severity of left ventricular dysfunction, as measured by left ventricular ejection fraction 1
• The presence of other high-risk features, such as a small valve area, high mean gradient, or rapid progression of stenosis 1
• The patient's overall clinical status, including the presence of any comorbidities or other cardiac conditions 1 The timing of intervention is critical, as waiting too long can lead to irreversible myocardial damage and worse outcomes, and surgical aortic valve replacement remains the gold standard treatment, though transcatheter aortic valve replacement (TAVR) has emerged as an alternative for high-risk surgical patients or those with prohibitive surgical risk 1.

From the Research

Indications for Aortic Valve Replacement

The indications for aortic valve replacement (AVR) include:

• Symptomatic severe aortic stenosis (AS) 2, 3, 4
• Asymptomatic severe AS, as early valve replacement may prevent irreversible cardiac remodeling 2, 3
• Severe aortic insufficiency (AI) 5
• Aortic regurgitation, where aortic valve repair or replacement may be considered 6
• Bicuspid aortic valve with feasible anatomy 2
• Small aortic annuli 2
• Low-flow, low-gradient AS 2
• Younger patients, although this has raised questions about valve durability and feasibility of reintervention 2

Patient Populations

AVR may be considered in various patient populations, including:

• High-risk patients 4
• Intermediate-risk patients 4
• Low-risk patients 4
• Patients with moderate or greater AI 5
• Patients with aortic regurgitation, where aortic valve repair or replacement may be considered 6

Outcomes

The outcomes of AVR may vary depending on the patient population and the type of procedure used, including:

• Operative mortality and morbidity 5
• Risk of death from any cause or cardiovascular mortality 4
• Risk of certain side effects, such as major bleeding, acute kidney injury, or new-onset atrial fibrillation 4
• Risk of reintervention or reoperation 6