ACC/AHA Guideline Summary: Indications for Aortic Valve replacement (AVR) in Aortic Stenosis (AS)

Class I - There is evidence and/or general agreement that AVR is indicated in patients with AS in the following settings

• Symptomatic Severe AS (see aortic valve, severity)
• Severe AS in patients undergoing coronary artery bypass graft surgery or surgery on the aorta or other heart valves.
• Severe AS with a left ventricular ejection fraction less than 50%

Class IIa - The weight of evidence or opinion is in favor of the usefulness of AVR in patients with AS in the following setting:

• Moderate AS in patients undergoing coronary artery bypass graft surgery or surgery on the aorta or other heart valves

Class IIb - The weight of evidence or opinion is less well established for the usefulness of AVR in patients with AS in the following settings:

• Severe AS in asymptomatic patients who have an abnormal response to exercise such as the development of symptoms or hypotension
• Severe AS in asymptomatic patients with a high likelihood of rapid progression (as determined by age, valve calcification, and coronary heart disease)
• Severe AS in asymptomatic patients in whom surgery might be delayed at the time of symptom onset.
• Mild AS in patients undergoing CABG in whom there is evidence, such as moderate to severe valve calcification, that progression may be rapid.
• Extremely severe AS (aortic valve area less than 0.6 cm2, mean gradient greater than 60 mmHg, and aortic jet velocity greater than 5 m/sec) in asymptomatic patients in whom the expected operative mortality is 1 percent or less.

Class III - There is evidence and / or general agreement that AVR for AS is not useful in the following setting:

• for the prevention of cardiac death in asymptomatic patients who have none of the class IIa or IIb findings.