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AS, aortic stenosis; EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; LV, left ventricular; SAS, severe aortic stenosis; sAVR, surgical aortic valve replacement; STS, Society of Thoracic Surgeons; TAVI, transcatheter aortic valve implantation. *Majority of asymptomatic patients should be put on watchful waiting and periodically re-evaluated. In some special cases they might benefit from referral to heart team. For more information, please consult the 2017 Guidelines. †Frailty should be diagnosed using a non-subjective assessment tool, and not using methods such as the 'eyeball' test.
1. Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), Baumgartner H, Falk V, Bax JJ et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease (version 2017). EHJ 2017;38:2739–91.
2. Lindman BR, Clavel MA, Mathieu P et al. Calcific aortic stenosis. Nature reviews Disease primers 2016; 2: 16006.
3. Mayo Clinic Sta�. www.mayoclinic.com https://www.mayoclinic.org/diseases-conditions/aortic-stenosis/symptomscauses/syc-20353139. Accessed January, 2018.
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Patient referral fromGeneral Practitioner
Shortness of breath2
Reduced physicalactivity level2
Chest pain ortightness2
Fatigue2 Dizziness, feeling faint or fainting upon
exertion2
Palpitations3
Suspicion of Aortic Stenosis (AS)
Diagnosis of severe AS confirmed
Identification of patients suitablefor transcatheter aortic valve implantation (TAVI) (Based on 2017 ESC/EACTS guidelines1)
Auscultation Echocardiography
For physically active patients, exercise testing is recommended for unmasking symptoms
STS or EuroSCORE II ≥4%
logistic EuroSCORE I ≥10%
or
Other risk factors not
included (e.g. frailty,
porcelain aorta, sequelae
of chest radiation)
Decision by Heart Team
according to individual
patient characteristics
sAVR TAVI
STS or EuroSCORE II <4%
logistic EuroSCORE I <10%
and
No other risk factors not included in scores (e.g. frailty, porcelain aorta, sequelae of chest radiation)
sAVRAs assessed
by Heart Team
TAVI
sAVR or TAVIAspects to be considered by Heart Team
for decision between TAVI and sAVR
Clinicalcharacteristics
Anatomicaland technical
STS/EuroSCORE II <4%
Age<75 ≥75
Endocarditissuspected
Frailty†
Restricted mobility and conditions a�ecting rehabilitation
Severe comorbiditynot reflected in score
Previouscardiac surgery
Sequelaeof chest
radiation
Suitable fortransfemoral
TAVI
Severe chestdeformationor scoliosis
Expected patient-prosthesis
mismatch
Aortaor LV
thrombi
Unfavourable access (any) for TAVI
Vascular/valveanatomy unsuitable
for TAVI
Concomitant cardiacsurgical intervention
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Heart Valve Centre
Recommendations for treatment of severe symptomatic AS
Patient evaluation
Decision on intervention
Assessment of Aortic Stenosis severity
Referral to Heart Team
ESC/EACTS Guidelinesrecommendations to
assist the Heart Team’s decision for choice of
intervention
Increasedsurgical risk
Low surgical risk
Not suitable for surgical aortic valve replacement (sAVR)
≥4%
Symptoms ofsevere AS confirmed
In special cases, asymptomatic patients might also be referred
to the Heart Team.*
sAVR TAVIor
Porcelainaorta
Presence of intactcoronary bypass
grafts at riskfollowing sternotomy