**Early elective surgery is indicated in asymptomatic patients with** [8]:


An update of proposed management strategy for patients with severe AS by Leal et al. [17] is shown in **Figure 1**, based on the ESC/EACTS and ACC/ AHA guidelines on the management of valvular heart disease [8, 18].

#### **Figure 1.**

*Management of severe aortic stenosis [8, 17, 18]. ACC/AHA recommendations have been shown in parentheses.*

**35**

*Current Management of Severe Aortic Stenosis in Intermediate Risk Patients*

Risk stratification applies to any sort of intervention and is required for weighing the risk of intervention against the expected natural history of VHD as a basis for decision making [8]. Nowadays, the STS score and logistic EuroSCORE II are the most commonly used. **The EuroSCORE I** overestimates operative mortality and its calibration of risk is poor, and *it should no longer be used to guide decision making,* but it has been used in many TAVI studies/registries and may still be useful to identify the subgroups of patients for decision between intervention modalities and to predict 1-year mortality [8]. **The EuroSCORE II** and the **Society of Thoracic Surgeons (STS)** scores more accurately discriminate highand low-risk surgical patients and show better calibration to predict postoperative outcome after valvular surgery [8]. Current models do not include some risk factors that may be particularly important in the prediction of outcomes, including frailty, pulmonary hypertension (PH), porcelain aorta, and the presence of

New scores have been developed to estimate the risk of 30-day mortality in patients undergoing TAVI, with better accuracy and discrimination, but not without certain limitations by a lack of consideration of frailty, disability, and cognitive function [19]. Examples of those are: FRANCE-2 risk score [20], the STS/ ACC TVT registry predictive model [21], and the TAVR risk score based on data from the German aortic valve registry [22]. A new tool based on the STS/ACC TVT Registry™ is an application for from the STS/ACC TVT Registry™ an application for mobile devices and web, call **"TAVR in-hospital mortality Risk app**" [23], in

order to inform physicians of the estimated risk of in-hospital mortality.

morbidity and mortality after surgery and TAVI [24].

their decision on the best treatment option.

procedure-specific impediments.

procedure-specific impediment.

*risk categories*: [19].

impediments.

It remains essential not to rely on a single risk score figure when assessing patients or to determine unconditionally the indication and type of intervention. *The role of the heart team* is essential to take all of these data into account and adopt a final decision on the best treatment strategy. It is important to take into account patient's life expectancy, expected quality of life, and patient preference, as well as local resources, in order to do a proper planning of intervention. There is a growing interest in the assessment of frailty, an overall marker of impairment of functional, cognitive, and nutritional status. Frailty is associated with increased

Finally, the patient and family should be thoroughly informed and assisted in

Actual **AHA/ACC guideline** classifies patients with severe AS into *four global* 

1.Low risk: STS <4% with no frailty, no comorbidity, and no procedure-specific

2.**Intermediate risk: STS 4-8%** with no more than mild frailty or one major organ system compromise not to be improved postoperatively and minimal

3.High risk: STS >8%, or moderate-severe frailty, no more than two major organ systems compromise not to be improved postoperatively, or a possible

tively or severe frailty or severe procedure-specific impediments.

4.Prohibitive risk: preoperative risk of mortality and morbidity >50% at 1 year or ≥three major organ systems compromises not to be improved postopera-

*DOI: http://dx.doi.org/10.5772/intechopen.83422*

**5. Risk stratification**

hepatic dysfunction.
