A 50-year-old asymptomatic man with established aoic stenosis undergoes Exercise Stress testing according to Bruce Protocol. The stress test was terminated at 11 minutes due to development of fatigue and dyspnea. Regional pressure gradient was observed to be 60 mm Hg between the two sides of the aoic valve. What is the best management.

Answer is B (Aoic valve replacement ) The patient in question has asymptomatic aoic stenosis but develops symptoms on exercise (abnormal/positive exercise test). Also the presence of mean pressure gradient of 60mm Hg put this patient into the category of 'Very Severe Aoic Stenosis' or 'Critical Aoic Stenosis'. Optimal management of asymptomatic severe Aoic Stenosis continues to be a source of ongoing clinical controversy. Surgical Aoic Valve Replacement and Watchfull waiting with frequent reassessments (observation), both continue to be legitimate though debatable treatment options. Since the patient in question has 'Very Severe AS' and 'Abnormal Stress Testing' he should be considered for surgical intervention in the form of Aoic Valve Replacement (A VR). 50-year-old patient with Asymptomatic Severe Aoic Stenosis =5m/s, mean gradient >=50mm Hg, aoic valve ara <=0.6 cm2) when operative moality is < 1% " align="left" height="132" width="316">Positive Exercise Stress Test Mean Pressure Gradient > 60 mm Hg Symptoms during exercise such as dyspnea, angina, and syncope or near syncope constitute positive criteria indicating an abnormal stress test in patients with asymptomatic aoic stenosis. Mean pressure gradient > 60 mm Hg and/or Aoic valve area < 0.6 cm'` and /or Aoic Jet velocity > 5.0 m per second is classified as 'Extremely Severe Aoic Stenosis' (Critical Aoic Stenosis) 'Severe Aoic Stenosis with an abnormal response to exercise is considered a Class Hb indication for Aoic Valve Replacement according to the ACC/AHA Guidelines.' 'Severe Aoic Stenosis with an abnormal response to exercise is considered a Class IC indication for Aoic Valve Replacement according to European Cardiology Society Guidelines (ECS Guidelines)' 'Extremely Severe Aoic Stenosis (mean gradient > 60 mm Hg) is considered a class Ilb indication for Aoic Valve Replacement according to the ACC/AHA Guidelines.' Study Conclusion I. 'Clinical outcomes in non-surgically 'Surgery should always be considered in very severe AS managed patients with very severe versus severe regardless of symptoms, and paicular attention needs to aoic stenosis' be paid to their extremely poor outcomes.' (Hea doi:O. 1136/heajn1-2011-300137; Valvular hea disease; Original aicle) 2. 'Early Surgery Versus Conventional 'Compared with the conventional treatment strategy, Treatment in Asymptomatic Very Severe Aoic early surgery is associated with improved survival by Stenosis' effectively decreasing cardiac moality and sudden (Tirculation': 2010; 121: 1502-1509; Valvular hea cardiac death in patients with very severe AS. This result disease; Original aicle) suggests that early surgery can be a therapeutic option to fuher improve clinical outcome in asymptomatic patients with very severe AS and low operative risk.' Classification of Aoic Valve Stenosis Severity Severity Valve Area (cm2) Maximum Aoic Velocity (m/sec)) Mean Pressure Gradient (mm Hg) Mild 1.5 - 2.0 2.5 - 3.0 <25 Moderate 1.0 -1.5 3.0-4.0 25-40 Severe 0.6-1.0 >4.0 >40 Critical (Extremely Severe) <0.6 >5.0 >50-60