Aortic Valve and Ascending Aorta

AVR is recommended in patients with severe AS at the onset of symptoms of dyspnea, angina, or lightheadedness or syncope. (B, Class I)

AVR is recommended, regardless of symptoms, with the identification of left ventricular (LV) systolic dysfunction (ejection fraction [EF] <50%). (C, Class I)

AVR is recommended in patients with severe AS who are scheduled to undergo coronary artery bypass graft surgery (CABG), surgery on other cardiac valves, or surgery on the aortic root or ascending aorta. (C, Class I)

AVR is reasonable in patients with moderate AS undergoing CABG or surgery on the aorta or other heart valves. (B, Class IIa)

Exercise testing in asymptomatic patients with AS to determine the need for AVR may be considered to elicit exercise-induced symptoms and abnormal blood pressure responses. (B, Class IIb)

AVR may be considered for asymptomatic patients with severe AS and abnormal response to exercise (eg, asymptomatic hypotension). (C, Class IIb)

AVR may be considered for adults with severe asymptomatic AS if there is a high likelihood of rapid progression (age, calcification, and CAD) or if surgery might be delayed at the time of symptom onset. (C, Class IIb)

AVR may be considered in patients undergoing CABG who have mild AS when there is evidence, such as moderate to severe valve calcification, that progression may be rapid. (C, Class IIb)

AVR may be considered for asymptomatic patients with extremely severe AS (aortic valve area [AVA] <0.6 cm², mean gradient >60 mm Hg, and jet velocity >5.0 m/s) when the patient’s expected operative mortality is less than 1%. (C, Class IIb)

AVR is not useful for the prevention of sudden death in asymptomatic patients with AS who have normal LV systolic function. (B, Class III)

AVR or repair is indicated for symptomatic patients with severe AR irrespective of LV systolic function. (B, Class I)

AVR or repair is recommended for asymptomatic patients with chronic severe AR and LV systolic dysfunction (EF ≤50%) at rest. (B, Class I)

AVR or repair is recommended in patients with chronic severe AR who are undergoing CABG or surgery on the aorta or other heart valves. (C, Class I)

VR or repair is reasonable for asymptomatic patients with severe AR with normal LV systolic function (EF >50%) but with severe LV dilation (end-diastolic dimension >75 mm or end-systolic dimension >55 mm). (B, Class IIa)

AVR or repair may be considered in patients with moderate AR who are undergoing CABG or surgery on the aorta or other heart valves. (C, Class IIb)

AVR or repair may be considered for asymptomatic patients with severe AR and normal LV systolic function at rest (EF >50%) when the degree of LV dilation exceeds an end-diastolic dimension of 70 mm or end-systolic dimension of 50 mm, when there is evidence of progressive LV dilation, declining exercise tolerance, or abnormal hemodynamic responses to exercise. (C, Class IIb)

AVR is not indicated for asymptomatic patients with mild, moderate, or severe AR and normal LV systolic function at rest (EF >50%) when the degree of LV dilation is not moderate or severe. (B, Class III)

AVR is recommended in patients with aortic valve infective endocarditis and severe heart failure or cardiogenic shock due to aortic valve dysfunction when there is a reasonable likelihood of recovery with satisfactory quality of life after surgery. (B, Class I)

Surgery is recommended in patients with annular or aortic abscesses, heart block, infections resistant to antibiotic therapy, and fungal endocarditis. (B, Class I)

Surgery to prevent embolization might be considered for patients with large vegetation size (>1.5 cm), especially if other relative indications for surgery are present (eg, severe AR) and the surgical risk is low. (C, Class IIb)