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

From the Guidelines

Aortic valve replacement (AVR) is indicated for patients with severe aortic stenosis who are symptomatic, have evidence of left ventricular dysfunction, or have very severe stenosis with a valve area <0.6 cm², as recommended by the most recent guidelines 1. The indications for AVR can be summarized as follows:

• Symptomatic severe aortic stenosis (AS) with symptoms such as angina, syncope, or heart failure
• Asymptomatic severe AS with left ventricular systolic dysfunction (ejection fraction < 50%) or abnormal exercise test
• Severe AS undergoing coronary artery bypass graft surgery (CABG), surgery of the ascending aorta, or another valve surgery
• Asymptomatic patients with very severe AS defined by a peak transvalvular velocity > 5.5 m/s or severe valve calcification with a rapid increase in peak transvalvular velocity of ≥ 0.3 m/s per year The decision to perform AVR should be based on a comprehensive evaluation of the patient's symptoms, valve severity, left ventricular function, and surgical risk, as outlined in the guidelines 1. Some key considerations in the decision-making process include:
• The presence of symptoms, such as angina, syncope, or heart failure, which are indicative of severe AS
• The severity of AS, as determined by valve area, mean gradient, and peak transvalvular velocity
• The presence of left ventricular systolic dysfunction or abnormal exercise test, which may indicate the need for earlier intervention
• The patient's surgical risk, which may influence the decision to perform surgical AVR or transcatheter aortic valve replacement (TAVR) 1. The most recent guidelines recommend that AVR be considered in patients with severe AS who are at low operative risk, with normal exercise performance, and have very severe AS or rapid progression of disease 1.

From the Research

Indications for Aortic Valve Replacement (AVR)

The indications for aortic valve replacement (AVR) are as follows:

• Severe aortic stenosis in the presence of symptoms or a left ventricular ejection fraction <50% 2
• Asymptomatic severe aortic stenosis with significant left ventricular dysfunction or dilatation 3, 4
• Symptomatic patients with severe aortic regurgitation 3
• Asymptomatic patients with severe aortic regurgitation and significant left ventricular dysfunction or dilatation 3
• Patients with moderate aortic stenosis and left ventricular dysfunction, as early valve replacement may prevent irreversible cardiac remodeling 5
• Patients with aortic stenosis and severe left ventricular dysfunction, where AVR has a survival equal to or exceeding that of heart transplantation 6

Specific Patient Populations

• Asymptomatic patients with preserved left ventricular function and severe aortic stenosis may benefit from early AVR, as it has been shown to reduce the risk of all-cause and cardiac death 4
• Patients with severe aortic regurgitation and moderate enlargement of the left ventricle should undergo regular check-ups in yearly intervals, while those with severe left ventricular dilatation should be checked every 6 months 3
• Patients with aortic stenosis and severe left ventricular dysfunction should be considered for AVR or heart transplantation, depending on the presence of coronary artery disease and other factors 6