Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10:1 25. 67. deFilippi CR, Willett DL, Brickner ME, et al. Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low trans- valvular gradients. Am J Cardiol. 1995;75:191 4. 68. Tarantini G, Covolo E, Razzolini R, et al. Valve replacement for severe aor- tic stenosis with low transvalvular gradient and left ventricular ejection fraction exceeding 0.50. Ann Thorac Surg. 2011;91:1808 15. 69. Clavel M-A, Dumesnil JG, Capoulade R, et al. Outcome of patients with aortic stenosis, small valve area, and low-flow, low-gradient de- spite preserved left ventricular ejection fraction. J Am Coll Cardiol. 2012;60:1259 67. 70. Lancellotti P, Magne J, Donal E, et al. Clinical outcome in asymptomatic se- vere aortic stenosis: insights from the new proposed aortic stenosis grad- ing classification. J Am Coll Cardiol. 2012;59:235 43. 71. Mehrotra P, Jansen K, Flynn AW, et al. Differential left ventricular remodel- ling and longitudinal function distinguishes low flow from normal-flow preserved ejection fraction low-gradient severe aortic stenosis. Eur Heart J. 2013;34:1906 14. 72. Lauten J, Rost C, Breithardt OA, et al. Invasive hemodynamic characteris- tics of low gradient severe aortic stenosis despite preserved ejection frac- tion. J Am Coll Cardiol. 2013;61:1799 808. 73. Mangner N, Stachel G, Woitek F, et al. Predictors of mortality and symp- tomatic outcome of patients with low-flow severe aortic stenosis under- going transcatheter aortic valve replacement. J Am Heart Assoc. 2018;7: e010287. 74. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017;38: 2739 91. 75. Ozkan A, Hachamovitch R, Kapadia SR, et al. Impact of aortic valve re- placement on outcome of symptomatic patients with severe aortic ste- nosis with low gradient and preserved left ventricular ejection fraction. Circulation. 2013;128:622 31. 76. Chan KL, Teo K, Dumesnil JG, et al. Effect of lipid lowering with rosuvas- tatin on progression of aortic stenosis: results of the Aortic Stenosis Pro- gression Observation: Measuring Effects Of Rosuvastatin (ASTRONOMER) trial. Circulation. 2010;121:306 14. 77. Lancellotti P, Lebois F, Simon M, et al. Prognostic importance of quantita- tive exercise Doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation. 2005;112:I377 82. 78. Das P, Rimington H, Chambers J. Exercise testing to stratify risk in aortic stenosis. Eur Heart J. 2005;26:1309 13. 79. Alborino D, Hoffmann JL, Fournet PC, et al. Value of exercise testing to evaluate the indication for surgery in asymptomatic patients with valvular aortic stenosis. J Heart Valve Dis. 2002;11:204 9. 80. Takeda S, Rimington H, Chambers J. Prediction of symptom-onset in aortic stenosis: a comparison of pressure drop/flow slope and haemodynamic measures at rest. Int J Cardiol. 2001;81:131 7. 81. Skalski J, Allison TG, Miller TD. The safety of cardiopulmonary exercise testing in a population with high-risk cardiovascular diseases. Circulation. 2012;126:2465 72. 82. Dayan V, Vignolo G, Magne J, et al. Outcome and impact of aortic valve replacement in patients with preserved LVEF and low-gradient aortic ste- nosis. J Am Coll Cardiol. 2015;66:2594 603. 3.2.4. Choice of Intervention 3.2.4.1. Choice of Mechanical Versus Bioprosthetic AVR 1. Goldstone AB, Chiu P, Baiocchi M, et al. Mechanical or biologic pros- theses for aortic-valve and mitral-valve replacement. N Engl J Med. 2017;377:1847 57. 2. Badhwar V, Ofenloch JC, Rovin JD, et al. Noninferiority of closely moni- tored mechanical valves to bioprostheses overshadowed by early mortality benefit in younger patients. Ann Thorac Surg. 2012;93:748 53. 3. Brown ML, Schaff HV, Lahr BD, et al. Aortic valve replacement in patients aged 50 to 70 years: improved outcome with mechanical versus biologic prostheses. J Thorac Cardiovasc Surg. 2008;135:878 84. 4. van Geldorp MWA, Eric Jamieson WR, Kappetein AP, et al. Patient out- come after aortic valve replacement with a mechanical or biological pros- thesis: weighing lifetime anticoagulant-related event risk against reopera- tion risk. J Thorac Cardiovasc Surg. 2009;137:881 6, 866.e1 5. 5. Kulik A, B dard P, Lam B-K, et al. Mechanical versus bioprosthetic valve replacement in middle-aged patients. Eur J Cardiothorac Surg. 2006;30:485 91. 6. Glaser N, Jackson V, Holzmann MJ, et al. Aortic valve replacement with mechanical vs. biological prostheses in patients aged 50 69 years. Eur Heart J. 2016;37:2658 67. CLINICAL STATEMENTS AND GUIDELINES 7. Chikwe J, Chiang YP, Egorova NN, et al. Survival and outcomes following bioprosthetic vs mechanical mitral valve replacement in patients aged 50 to 69 years. JAMA. 2015;313:1435 42. 8. McClure RS, McGurk S, Cevasco M, et al. Late outcomes comparison of nonelderly patients with stented bioprosthetic and mechanical valves in the aortic position: a propensity-matched analysis. J Thorac Cardiovasc Surg. 2014;148:1931 9. 9. Chiang YP, Chikwe J, Moskowitz AJ, et al. Survival and long-term out- comes following bioprosthetic vs mechanical aortic valve replacement in patients aged 50 to 69 years. JAMA. 2014;312:1323 9. 10. Kaneko T, Aranki S, Javed Q, et al. Mechanical versus bioprosthetic mitral valve replacement in patients <65 years old. J Thorac Cardiovasc Surg. 2014;147:117 26. 11. Buratto E, Shi WY, Wynne R, et al. Improved survival after the Ross pro- cedure compared with mechanical aortic valve replacement. J Am Coll Cardiol. 2018;71:1337 44. 12. El-Hamamsy I, Eryigit Z, Stevens L-M, et al. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet. 2010;376:524 31. 13. Martin E, Mohammadi S, Jacques F, et al. Clinical outcomes following the Ross procedure in adults: a 25-year longitudinal study. J Am Coll Cardiol. 2017;70:1890 9. 14. Bourguignon T, Bouquiaux-Stablo A-L, Loardi C, et al. Very late outcomes for mitral valve replacement with the Carpentier-Edwards pericardial bio- prosthesis: 25-year follow-up of 450 implantations. J Thorac Cardiovasc Surg. 2014;148:2004 11.e1. 15. Bourguignon T, El Khoury R, Candolfi P, et al. Very long-term outcomes of the Carpentier-Edwards PERIMOUNT aortic valve in patients aged 60 or younger. Ann Thorac Surg. 2015;100:853 9. 16. Tuzcu EM, Kapadia SR, Vemulapalli S, et al. Transcatheter aortic valve re- placement of failed surgically implanted bioprostheses: the STS/ACC reg- istry. J Am Coll Cardiol. 2018;72:370 82. 17. Ye J, Cheung A, Yamashita M, et al. Transcatheter aortic and mitral valve- in-valve implantation for failed surgical bioprosthetic valves: an 8-year single-center experience. JACC Cardiovasc Interv. 2015;8:1735 44. 18. Dvir D, Webb JG, Bleiziffer S, et al. Transcatheter aortic valve implantation in failed bioprosthetic surgical valves. JAMA. 2014;312:162 70. 19. Dvir D, Webb J, Brecker S, et al. Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in- valve registry. Circulation. 2012;126:2335 44. 20. Coylewright M, Forrest JK, McCabe JM, et al. TAVR in low-risk patients: FDA approval, the new NCD, and shared decision-making. J Am Coll Car- diol. 2020;75:1208 11. 21. Hess EP, Coylewright M, Frosch DL, et al. Implementation of shared deci- sion making in cardiovascular care: past, present, and future. Circ Cardio- vasc Qual Outcomes. 2014;7:797 803. 22. Weber A, Noureddine H, Englberger L, et al. Ten-year comparison of peri- cardial tissue valves versus mechanical prostheses for aortic valve replace- ment in patients younger than 60 years of age. J Thorac Cardiovasc Surg. 2012;144:1075 83. 23. Hammermeister K, Sethi GK, Henderson WG, et al. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol. 2000;36:1152 8. 24. Chan V, Jamieson WRE, Germann E, et al. Performance of bioprostheses and mechanical prostheses assessed by composites of valve-related com- plications to 15 years after aortic valve replacement. J Thorac Cardiovasc Surg. 2006;131:1267 73. 25. Dunning J, Gao H, Chambers J, et al. Aortic valve surgery: marked increas- es in volume and significant decreases in mechanical valve use an analysis of 41,227 patients over 5 years from the Society for Cardiothoracic Sur- gery in Great Britain and Ireland National database. J Thorac Cardiovasc Surg. 2011;142:776 82.e3. 26. Stassano P, L. DT, Monaco M, et al. Aortic valve replacement: a prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years. J Am Coll Cardiol. 2009;54:1862 8. 27. Brennan JM, Edwards FH, Zhao Y, et al. Long-term safety and effective- ness of mechanical versus biologic aortic valve prostheses in older pa- tients: results from the Society of Thoracic Surgeons Adult Cardiac Surgery National Database. Circulation. 2013;127:1647 55. 28. Banbury MK, Cosgrove DM 3rd, Thomas JD, et al. Hemodynamic stability during 17 years of the Carpentier-Edwards aortic pericardial bioprosthesis. Ann Thorac Surg. 2002;73:1460 5. 29. Dellgren G, David TE, Raanani E, et al. Late hemodynamic and clinical out- comes of aortic valve replacement with the Carpentier-Edwards Perimount pericardial bioprosthesis. J Thorac Cardiovasc Surg. 2002;124:146 54. 30. Borger MA, Ivanov J, Armstrong S, et al. Twenty-year results of the Han- cock II bioprosthesis. J Heart Valve Dis. 2006;15:49 55. 31. Myk n PSU, Bech-Hansen O. A 20-year experience of 1712 patients with the Biocor porcine bioprosthesis. J Thorac Cardiovasc Surg. 2009;137:76 81. 32. Mazine A, El-Hamamsy I, Verma S, et al. Ross procedure in adults for car- diologists and cardiac Surgeons: JACC state-of-the-art review. J Am Coll Cardiol. 2018;72:2761 77. 3.2.4.2. Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate 1. Siemieniuk RA, Agoritsas T, Manja V, et al. Transcatheter versus surgi- cal aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk: systematic review and meta-analysis. BMJ. 2016;354:i5130. 2. Foroutan F, Guyatt GH, O Brien K, et al. Prognosis after surgical replace- ment with a bioprosthetic aortic valve in patients with severe symptom- atic aortic stenosis: systematic review of observational studies. BMJ. 2016;354:i5065. 3. Siontis GCM, Overtchouk P, Cahill TJ, et al. Transcatheter aortic valve im- plantation vs. surgical aortic valve replacement for treatment of symp- tomatic severe aortic stenosis: an updated meta-analysis. Eur Heart J. 2019;40:3143 53. 4. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replace- ment with a self-expanding prosthesis. N Engl J Med. 2014;370:1790 8. 5. Mack MJ, Leon MB, Smith CR, et al. 5-year outcomes of transcatheter aor- tic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet. 2015;385:2477 84. 6. Deeb GM, Reardon MJ, Chetcuti S, et al. 3-Year outcomes in high-risk pa- tients who underwent surgical or transcatheter aortic valve replacement. J Am Coll Cardiol. 2016;67:2565 74. 7. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609 20. 8. Thourani VH, Kodali S, Makkar RR, et al. Transcatheter aortic valve re- placement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet. 2016;387:2218 25. 9. Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replace- ment with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380:1695 705. 10. Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve re- placement with a self-expanding valve in low-risk patients. N Engl J Med. 2019;380:1706 15. 11. Siontis KC, Killu AM. Silent and non-silent thromboembolic events after ventricular tachycardia ablation: modifiable risk with postprocedure anti- coagulation? J Cardiovasc Electrophysiol. 2019;30:1197 9. 12. Kapadia SR, Leon MB, Makkar RR, et al. 5-Year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet. 2015;385:2485 91. 13. Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replace- ment using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014;63:1972 81. 14. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implanta- tion for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597 607. 15. Kodali SK, Williams MR, Smith CR, et al. Two-year outcomes af- ter transcatheter or surgical aortic-valve replacement. N Engl J Med. 2012;366:1686 95. 16. Burke CR, Kirkpatrick JN, Otto CM. Goals of care in patients with severe aortic stenosis. Eur Heart J. 2020;41:929 32. 17. Otto CM. Informed shared decisions for patients with aortic stenosis. N Engl J Med. 2019;380:1769 70. 18. Social Security Administration (US). Actuarial Life Table. Available at: 2020. 19. Salaun E, Clavel M-A, Rod s-Cabau J, et al. Bioprosthetic aortic valve durability in the era of transcatheter aortic valve implantation. Heart. 2018;104:1323 32. CLINICAL STATEMENTS AND GUIDELINES 20. Nishimura RA, O Gara PT, Bavaria JE, et al. 2019 AATS/ACC/ASE/SCAI/STS ex- pert consensus systems of care document: a proposal to optimize care for patients with valvular heart disease: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2019;73:2609 35. 21. Kumar A, Sato K, Banerjee K, et al. Hemodynamic durability of transcath- eter aortic valves using the updated Valve Academic Research Consor- tium-2 criteria. Catheter Cardiovasc Interv. 2019;93:729 38. 22. Foroutan F, Guyatt GH, Otto CM, et al. Structural valve deterioration after transcatheter aortic valve implantation. Heart. 2017;103:1899 905. 23. Abdel-Wahab M, Neumann F-J, Mehilli J, et al. 1-Year outcomes after transcatheter aortic valve replacement with balloon-expandable versus self-expandable valves: results from the CHOICE randomized clinical trial. J Am Coll Cardiol. 2015;66:791 800. 24. Lytvyn L, Guyatt GH, Manja V, et al. Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic steno- sis: a systematic review. BMJ Open. 2016;6:e014327. 25. Otto CM, Kumbhani DJ, Alexander KP, et al. 2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the man- agement of adults with aortic stenosis: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2017;69:1313 46. 26. Abdel-Wahab M, Landt M, Neumann FJ, et al. 5-Year outcomes af- ter TAVR with balloon-expandable versus self-expanding valves: results from the CHOICE Randomized Clinical Trial. JACC Cardiovasc Interv. 2020;13:1071 82. 27. Deharo P, Bisson A, Herbert J, et al. Impact of Sapien 3 balloon-expandable versus Evolut R self-expandable transcatheter aortic valve implantation in patients with aortic stenosis: data from a nationwide analysis. Circulation. 2020;141:260 8. 28. Van Belle E, Vincent F, Labreuche J, et al. Balloon-expandable versus self- expanding transcatheter aortic valve replacement: a propensity-matched comparison from the FRANCE-TAVI Registry. Circulation. 2020;141:243 59. 29. Furer A, Chen S, Redfors B, et al. Effect of baseline left ventricular ejection fraction on 2-year outcomes after transcatheter aortic valve replacement: analysis of the PARTNER 2 trials. Circ Heart Fail. 2019;12:e005809. 30. Ribeiro HB, Lerakis S, Gilard M, et al. Transcatheter aortic valve replace- ment in patients with low-flow, low-gradient aortic stenosis: the TOPAS- TAVI registry. J Am Coll Cardiol. 2018;71:1297 308. 31. Schewel J, Schl ter M, Schmidt T, et al. Early haemodynamic changes and long-term outcome of patients with severe low-gradient aortic stenosis after transcatheter aortic valve replacement. EuroIntervention. 2020;15:1181 9. 32. Maes F, Lerakis S, Barbosa Ribeiro H, et al. Outcomes from transcatheter aortic valve replacement in patients with low-flow, low-gradient aortic stenosis and left ventricular ejection fraction less than 30%: a substudy from the TOPAS-TAVI registry. JAMA Cardiol. 2019;4:64 70. 33. Elmariah S, Fearon WF, Inglessis I, et al. Transapical transcatheter aortic valve replacement is associated with increased cardiac mortality in pa- tients with left ventricular dysfunction: insights from the PARTNER I trial. JACC Cardiovasc Interv. 2017;10:2414 22. 34. Makkar RR, Fontana GP, Jilaihawi H, et al. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med. 2012;366:1696 704. 35. Kolte D, Khera S, Vemulapalli S, et al. Outcomes following urgent/emer- gent transcatheter aortic valve replacement: insights from the STS/ACC TVT registry. JACC Cardiovasc Interv. 2018;11:1175 85. 36. Nagao K, Taniguchi T, Morimoto T, et al. Acute heart failure in patients with severe aortic stenosis insights from the CURRENT AS registry. Circ J. 2018;82:874 85. 37. Szerlip M, Arsalan M, Mack MC, et al. Usefulness of balloon aortic valvu- loplasty in the management of patients with aortic stenosis. Am J Cardiol. 2017;120:1366 72. 38. Bongiovanni D, K hl C, Bleiziffer S, et al. Emergency treatment of decom- pensated aortic stenosis. Heart. 2018;104:23 9. 4. AORTIC REGURGITATION 4.1. Acute Aortic Regurgitation 4.1.1. Diagnosis of AR 1. Hamirani YS, Dietl CA, Voyles W, et al. Acute aortic regurgitation. Circula- tion. 2012;126:1121 6. 2. Stout KK, Verrier ED. Acute valvular regurgitation. Circulation. 2009;119:3232 41. 3. Patel PA, Bavaria JE, Ghadimi K, et al. Aortic regurgitation in acute type-A aortic dissection: a clinical classification for the perioperative echocardiog- rapher in the era of the functional aortic annulus. J Cardiothorac Vasc Anesth. 2018;32:586 97. 1. Hamirani YS, Dietl CA, Voyles W, et al. Acute aortic regurgitation. Circula- tion. 2012;126:1121 6. 2. Stout KK, Verrier ED. Acute valvular regurgitation. Circulation. 2009;119:3232 41. 3. Lalani T, Cabell CH, Benjamin DK, et al. Analysis of the impact of early sur- gery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias. Circulation. 2010;121:1005 13. 4. Patel PA, Bavaria JE, Ghadimi K, et al. Aortic regurgitation in acute type-A aortic dissection: a clinical classification for the perioperative echocardiog- rapher in the era of the functional aortic annulus. J Cardiothorac Vasc Anesth. 2018;32:586 97. 5. Trost JC, Hillis LD. Intra-aortic balloon counterpulsation. Am J Cardiol. 2006;97:1391 8. 4.3. Chronic AR 4.3.1. Diagnosis of Chronic AR 1. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninva- sive evaluation of native valvular regurgitation: a report from the Ameri- can Society of Echocardiography. Developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017;30:303 71. 2. Detaint D, Messika-Zeitoun D, Maalouf J, et al. Quantitative echocar- diographic determinants of clinical outcome in asymptomatic patients with aortic regurgitation: a prospective study. JACC Cardiovasc Imaging. 2008;1:1 11. 3. Pizarro R, Bazzino OO, Oberti PF, et al. Prospective validation of the prog- nostic usefulness of B-type natriuretic peptide in asymptomatic patients with chronic severe aortic regurgitation. J Am Coll Cardiol. 2011;58:1705 14. 4. Bonow RO, Picone AL, McIntosh CL, et al. Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: im- pact of preoperative left ventricular function. Circulation. 1985;72:1244 56. 5. Cunha CL, Giuliani ER, Fuster V, et al. Preoperative M-mode echocardiog- raphy as a predictor of surgical results in chronic aortic insufficiency. J Thorac Cardiovasc Surg. 1980;79:256 65. 6. Bonow RO, Lakatos E, Maron BJ, et al. Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function. Circulation. 1991;84:1625 35. 7. Bonow RO, Rosing DR, McIntosh CL, et al. The natural history of asymp- tomatic patients with aortic regurgitation and normal left ventricular func- tion. Circulation. 1983;68:509 17. 8. Borer JS, Hochreiter C, Herrold EM, et al. Prediction of indications for valve replacement among asymptomatic or minimally symptomatic patients with chronic aortic regurgitation and normal left ventricular performance. Circulation. 1998;97:525 34. 9. Ishii K, Hirota Y, Suwa M, et al. Natural history and left ventricular re- sponse in chronic aortic regurgitation. Am J Cardiol. 1996;78:357 61. 10. Scognamiglio R, Fasoli G, Dalla Volta S. Progression of myocardial dysfunc- tion in asymptomatic patients with severe aortic insufficiency. Clin Cardiol. 1986;9:151 6. 11. Scognamiglio R, Rahimtoola SH, Fasoli G, et al. Nifedipine in asymptom- atic patients with severe aortic regurgitation and normal left ventricular function. N Engl J Med. 1994;331:689 94. 12. Siemienczuk D, Greenberg B, Morris C, et al. Chronic aortic insufficiency: factors associated with progression to aortic valve replacement. Ann In- tern Med. 1989;110:587 92. 13. Tornos MP, Olona M, Permanyer-Miralda G, et al. Clinical outcome of se- vere asymptomatic chronic aortic regurgitation: a long-term prospective follow-up study. Am Heart J. 1995;130:333 9. 14. Tarasoutchi F, Grinberg M, Spina GS, et al. Ten-year clinical laboratory follow-up after application of a symptom-based therapeutic strategy to CLINICAL STATEMENTS AND GUIDELINES patients with severe chronic aortic regurgitation of predominant rheu- matic etiology. J Am Coll Cardiol. 2003;41:1316 24. 15. Saisho H, Arinaga K, Kikusaki S, et al. Long term results and predictors of left ventricular function recovery after aortic valve replacement for chronic aortic regurgitation. Ann Thorac Cardiovasc Surg. 2015;21:388 95. 16. Mentias A, Feng K, Alashi A, et al. Long-term outcomes in patients with aortic regurgitation and preserved left ventricular ejection fraction. J Am Coll Cardiol. 2016;68:2144 53. 17. Yang L-T, Michelena HI, Scott CG, et al. Outcomes in chronic hemodynam- ically significant aortic regurgitation and limitations of current guidelines. J Am Coll Cardiol. 2019;73:1741 52. 18. de Meester C, Gerber BL, Vancraeynest D, et al. Do guideline-based indi- cations result in an outcome penalty for patients with severe aortic regur- gitation? JACC Cardiovasc Imaging. 2019;12:2126 38. 19. Yang LT, Enriquez-Sarano M, Michelena HI, et al. Predictors of progres- sion in patients with stage B aortic regurgitation. J Am Coll Cardiol. 2019;74:2480 92. 20. Cawley PJ, Hamilton-Craig C, Owens DS, et al. Prospective comparison of valve regurgitation quantitation by cardiac magnetic resonance imaging and transthoracic echocardiography. Circ Cardiovasc Imaging. 2013;6:48 57. 21. Cranney GB, Lotan CS, Dean L, et al. Left ventricular volume measure- ment using cardiac axis nuclear magnetic resonance imaging. Validation by calibrated ventricular angiography. Circulation. 1990;82:154 63. 22. Dulce MC, Mostbeck GH, O Sullivan M, et al. Severity of aortic regurgi- tation: interstudy reproducibility of measurements with velocity-encoded cine MR imaging. Radiology. 1992;185:235 40. 23. Gelfand EV, Hughes S, Hauser TH, et al. Severity of mitral and aortic re- gurgitation as assessed by cardiovascular magnetic resonance: optimizing correlation with Doppler echocardiography. J Cardiovasc Magn Reson. 2006;8:503 7. 24. Myerson SG, d Arcy J, Mohiaddin R, et al. Aortic regurgitation quantifi- cation using cardiovascular magnetic resonance: association with clinical outcome. Circulation. 2012;126:1452 60. 25. Kammerlander AA, Wiesinger M, Duca F, et al. Diagnostic and prognos- tic utility of cardiac magnetic resonance imaging in aortic regurgitation. JACC Cardiovasc Imaging. 2019;12:1474 83. 26. Teague SM, Heinsimer JA, Anderson JL, et al. Quantification of aortic re- gurgitation utilizing continuous wave Doppler ultrasound. J Am Coll Car- diol. 1986;8:592 9. 27. Attenhofer Jost CH, Turina J, Mayer K, et al. Echocardiography in the eval- uation of systolic murmurs of unknown cause. Am J Med. 2000;108:614 20. 28. Benjelloun H, Cranney GB, Kirk KA, et al. Interstudy reproducibility of bi- plane cine nuclear magnetic resonance measurements of left ventricular function. Am J Cardiol. 1991;67:1413 20. 29. Buser PT, Auffermann W, Holt WW, et al. Noninvasive evaluation of global left ventricular function with use of cine nuclear magnetic resonance. J Am Coll Cardiol. 1989;13:1294 300. 30. Van Rossum AC, Visser FC, Sprenger M, et al. Evaluation of magnetic resonance imaging for determination of left ventricular ejection fraction and comparison with angiography. Am J Cardiol. 1988;62:628 33. 4.3.2. Medical Therapy 1. Evangelista A, Tornos P, Sambola A, et al. Long-term vasodilator therapy in patients with severe aortic regurgitation. N Engl J Med. 2005;353:1342 9. 2. Scognamiglio R, Rahimtoola SH, Fasoli G, et al. Nifedipine in asymptom- atic patients with severe aortic regurgitation and normal left ventricular function. N Engl J Med. 1994;331:689 94. 3. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e596 646. 4. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136:e137 61. 5. Elder DHJ, Wei L, Szwejkowski BR, et al. The impact of renin-angiotensin- aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation: a large population cohort study. J Am Coll Cardiol. 2011;58:2084 91. 6. Fioretti P, Benussi B, Scardi S, et al. Afterload reduction with nifedipine in aortic insufficiency. Am J Cardiol. 1982;49:1728 32. 7. Lin M, Chiang HT, Lin SL, et al. Vasodilator therapy in chronic asymptom- atic aortic regurgitation: enalapril versus hydralazine therapy. J Am Coll Cardiol. 1994;24:1046 53. 8. S ndergaard L, Aldershvile J, Hildebrandt P, et al. Vasodilatation with felodipine in chronic asymptomatic aortic regurgitation. Am Heart J. 2000;139:667 74. 9. Sampat U, Varadarajan P, Turk R, et al. Effect of beta-blocker therapy on survival in patients with severe aortic regurgitation results from a cohort of 756 patients. J Am Coll Cardiol. 2009;54:452 7. 4.3.3. Timing of Intervention 1. Bonow RO, Borer JS, Rosing DR, et al. Preoperative exercise capacity in symptomatic patients with aortic regurgitation as a predictor of post- operative left ventricular function and long-term prognosis. Circulation. 1980;62:1280 90. 2. Klodas E, Enriquez-Sarano M, Tajik AJ, et al. Optimizing timing of surgical correction in patients with severe aortic regurgitation: role of symptoms. J Am Coll Cardiol. 1997;30:746 52. 3. Chaliki HP, Mohty D, Avierinos J-F, et al. Outcomes after aortic valve re- placement in patients with severe aortic regurgitation and markedly re- duced left ventricular function. Circulation. 2002;106:2687 93. 4. Tornos P, Sambola A, Permanyer-Miralda G, et al. Long-term outcome of surgically treated aortic regurgitation: influence of guideline adherence toward early surgery. J Am Coll Cardiol. 2006;47:1012 7. 5. Bhudia SK, McCarthy PM, Kumpati GS, et al. Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ven- tricular dysfunction. J Am Coll Cardiol. 2007;49:1465 71. 6. Fiedler AG, Bhambhani V, Laikhter E, et al. Aortic valve replacement as- sociated with survival in severe regurgitation and low ejection fraction. Heart. 2018;104:835 40. 7. Kaneko T, Ejiofor JI, Neely RC, et al. Aortic regurgitation with markedly reduced left ventricular function is not a contraindication for aortic valve replacement. Ann Thorac Surg. 2016;102:41 7. 8. Greves J, Rahimtoola SH, McAnulty JH, et al. Preoperative criteria predic- tive of late survival following valve replacement for severe aortic regurgita- tion. Am Heart J. 1981;101:300 8. 9. Forman R, Firth BG, Barnard MS. Prognostic significance of preoperative left ventricular ejection fraction and valve lesion in patients with aortic valve replacement. Am J Cardiol. 1980;45:1120 5. 10. Bonow RO, Picone AL, McIntosh CL, et al. Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: im- pact of preoperative left ventricular function. Circulation. 1985;72:1244 56. 11. Cormier B, Vahanian A, Luxereau P, et al. Should asymptomatic or mildly symptomatic aortic regurgitation be operated on? Z Kardiol. 1986;75(sup- pl 2):141 5. 12. Klodas E, Enriquez-Sarano M, Tajik AJ, et al. Aortic regurgitation compli- cated by extreme left ventricular dilation: long-term outcome after surgi- cal correction. J Am Coll Cardiol. 1996;27:670 7. 13. Saisho H, Arinaga K, Kikusaki S, et al. Long term results and predictors of left ventricular function recovery after aortic valve replacement for chronic aortic regurgitation. Ann Thorac Cardiovasc Surg. 2015;21:388 95. 14. Mentias A, Feng K, Alashi A, et al. Long-term outcomes in patients with aortic regurgitation and preserved left ventricular ejection fraction. J Am Coll Cardiol. 2016;68:2144 53. 15. Yang L-T, Michelena HI, Scott CG, et al. Outcomes in chronic hemodynam- ically significant aortic regurgitation and limitations of current guidelines. J Am Coll Cardiol. 2019;73:1741 52. 16. de Meester C, Gerber BL, Vancraeynest D, et al. Do guideline-based indi- cations result in an outcome penalty for patients with severe aortic regur- gitation? JACC Cardiovasc Imaging. 2019;12:2126 38. 17. Bonow RO, Lakatos E, Maron BJ, et al. Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function. Circulation. 1991;84:1625 35. 18. Detaint D, Messika-Zeitoun D, Maalouf J, et al. Quantitative echocar- diographic determinants of clinical outcome in asymptomatic patients with aortic regurgitation: a prospective study. JACC Cardiovasc Imaging. 2008;1:1 11. 19. Pizarro R, Bazzino OO, Oberti PF, et al. Prospective validation of the prognos- tic usefulness of B-type natriuretic peptide in asymptomatic patients with chronic severe aortic regurgitation. J Am Coll Cardiol. 2011;58:1705 14. 20. Tornos MP, Olona M, Permanyer-Miralda G, et al. Clinical outcome of se- vere asymptomatic chronic aortic regurgitation: a long-term prospective follow-up study. Am Heart J. 1995;130:333 9. CLINICAL STATEMENTS AND GUIDELINES 21. Tarasoutchi F, Grinberg M, Spina GS, et al. Ten-year clinical laboratory follow-up after application of a symptom-based therapeutic strategy to patients with severe chronic aortic regurgitation of predominant rheu- matic etiology. J Am Coll Cardiol. 2003;41:1316 24. hypertrophy, wall stress and end-systolic dimension as echocardiographic predictors of normalization of left ventricular dilatation after valve replace- ment in chronic aortic insufficiency. Am J Cardiol. 1982;49:1091 100. 23. Fioretti P, Roelandt J, Bos RJ, et al. Echocardiography in chronic aortic in- sufficiency. Is valve replacement too late when left ventricular end-systolic dimension reaches 55 mm? Circulation. 1983;67:216 21. 24. Stone PH, Clark RD, Goldschlager N, et al. Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement. J Am Coll Cardiol. 1984;3:1118 26. 25. Zhang Z, Yang J, Yu Y, et al. Preoperative ejection fraction determines early recovery of left ventricular end-diastolic dimension after aortic valve replacement for chronic severe aortic regurgitation. J Surg Res. 2015;196:49 55. 26. Murashita T, Schaff HV, Suri RM, et al. Impact of left ventricular systolic function on outcome of correction of chronic severe aortic valve regurgi- tation: implications for timing of surgical intervention. Ann Thorac Surg. 2017;103:1222 8. 27. Wang Y, Jiang W, Liu J, et al. Early surgery versus conventional treatment for asymptomatic severe aortic regurgitation with normal ejection fraction and left ventricular dilatation. Eur J Cardiothorac Surg. 2017;52:118 24. 28. Scognamiglio R, Rahimtoola SH, Fasoli G, et al. Nifedipine in asymptom- atic patients with severe aortic regurgitation and normal left ventricular function. N Engl J Med. 1994;331:689 94. 29. Sawaya FJ, Deutsch MA, Seiffert M, et al. Safety and efficacy of transcath- eter aortic valve replacement in the treatment of pure aortic regurgitation in native valves and failing surgical bioprostheses: results from an Interna- tional Registry Study. JACC Cardiovasc Interv. 2017;10:1048 56. 30. Roy DA, Schaefer U, Guetta V, et al. Transcatheter aortic valve implanta- tion for pure severe native aortic valve regurgitation. J Am Coll Cardiol. 2013;61:1577 84. 31. Seiffert M, Bader R, Kappert U, et al. Initial German experience with transapical implantation of a second-generation transcatheter heart valve for the treatment of aortic regurgitation. JACC Cardiovasc Interv. 2014;7:1168 74. 32. Jiang J, Liu X, He Y, et al. Transcatheter aortic valve replacement for pure native aortic valve regurgitation: a systematic review. Cardiology. 2018;141:132 40. 33. Aicher D, Kunihara T, Abou Issa O, et al. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation. 2011;123:178 85. 34. David TE, Armstrong S, Ivanov J, et al. Aortic valve sparing operations: an update. Ann Thorac Surg. 1999;67:1840 2. 35. Kallenbach K, Hagl C, Walles T, et al. Results of valve-sparing aor- tic root reconstruction in 158 consecutive patients. Ann Thorac Surg. 2002;74:2026 32. 36. Pettersson GB, Crucean AC, Savage R, et al. Toward predictable repair of regurgitant aortic valves: a systematic morphology-directed approach to bicommissural repair. J Am Coll Cardiol. 2008;52:40 9. 37. de Kerchove L, Boodhwani M, Glineur D, et al. Valve sparing-root replace- ment with the reimplantation technique to increase the durability of bi- cuspid aortic valve repair. J Thorac Cardiovasc Surg. 2011;142:1430 8. 38. Kari FA, Liang DH, Kvitting J-PE, et al. Tirone David valve-sparing aortic root replacement and cusp repair for bicuspid aortic valve disease. J Tho- rac Cardiovasc Surg. 2013;145:S35 40.e1 2. 39. Ouzounian M, Rao V, Manlhiot C, et al. Valve-sparing root replacement compared with composite valve graft procedures in patients with aortic root dilation. J Am Coll Cardiol. 2016;68:1838 47. 40. Gleason TG. New graft formulation and modification of the David reim- plantation technique. J Thorac Cardiovasc Surg. 2005;130:601 3. 41. le Polain de Waroux JB, Pouleur AC, Robert A, et al. Mechanisms of recur- rent aortic regurgitation after aortic valve repair: predictive value of intra- operative transesophageal echocardiography. JACC Cardiovasc Imaging. 2009;2:931 9. 42. Boodhwani M, de Kerchove L, Glineur D, et al. Repair-oriented classifi- cation of aortic insufficiency: impact on surgical techniques and clinical outcomes. J Thorac Cardiovasc Surg. 2009;137:286 94. 43. Borow KM, Green LH, Mann T, et al. End-systolic volume as a predictor of postoperative left ventricular performance in volume overload from valvu- lar regurgitation. Am J Med. 1980;68:655 63. 44. Pizarro R, Bazzino OO, Oberti PF, et al. Prospective validation of the prog- nostic usefulness of B-type natriuretic peptide in asymptomatic patients with chronic severe aortic regurgitation. J Am Coll Cardiol. 2011;58:1705 14. 45. Myerson SG, d Arcy J, Mohiaddin R, et al. Aortic regurgitation quantifi- cation using cardiovascular magnetic resonance: association with clinical outcome. Circulation. 2012;126:1452 60. 46. Kammerlander AA, Wiesinger M, Duca F, et al. Diagnostic and prognos- tic utility of cardiac magnetic resonance imaging in aortic regurgitation. JACC Cardiovasc Imaging. 2019;12:1474 83. 47. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28:1 39.e14. 48. Kawel-Boehm N, Maceira A, Valsangiacomo-Buechel ER, et al. Normal values for cardiovascular magnetic resonance in adults and children. J Cardiovasc Magn Reson. 2015;17:29. 49. Lee JKT, Franzone A, Lanz J, et al. Early detection of subclinical myocardial damage in chronic aortic regurgitation and strategies for timely treatment of asymptomatic patients. Circulation. 2018;137:184 96. 50. Alashi A, Mentias A, Abdallah A, et al. Incremental prognostic utility of left ventricular global longitudinal strain in asymptomatic patients with significant chronic aortic regurgitation and preserved left ventricular ejec- tion fraction. JACC Cardiovasc Imaging. 2018;11:673 82. 51. Olsen NT, Sogaard P, Larsson HB, et al. Speckle-tracking echocardiography for predicting outcome in chronic aortic regurgitation during conservative management and after surgery. JACC Cardiovasc Imaging. 2011;4:223 30. 52. Dujardin KS, Enriquez-Sarano M, Schaff HV, et al. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study. Circulation. 1999;99:1851 7. 53. Bonow RO, Dodd JT, Maron BJ, et al. Long-term serial changes in left ven- tricular function and reversal of ventricular dilatation after valve replace- ment for chronic aortic regurgitation. Circulation. 1988;78:1108 20. 54. Carabello BA, Williams H, Gash AK, et al. Hemodynamic predictors of outcome in patients undergoing valve replacement. Circulation. 1986;74:1309 16. 55. Cunha CL, Giuliani ER, Fuster V, et al. Preoperative M-mode echocardiog- raphy as a predictor of surgical results in chronic aortic insufficiency. J Thorac Cardiovasc Surg. 1980;79:256 65. 56. Daniel WG, Hood WP Jr, Siart A, et al. Chronic aortic regurgitation: reas- sessment of the prognostic value of preoperative left ventricular end-sys- tolic dimension and fractional shortening. Circulation. 1985;71:669 80. 57. Henry WL, Bonow RO, Borer JS, et al. Observations on the optimum time for operative intervention for aortic regurgitation. I. Evaluation of the results of aortic valve replacement in symptomatic patients. Circulation. 1980;61:471 83. 58. Michel PL, Iung B, Abou Jaoude S, et al. The effect of left ventricular systolic function on long term survival in mitral and aortic regurgitation. J Heart Valve Dis. 1995;4(suppl 2):S160 8. 59. Sheiban I, Trevi GP, Casarotto D, et al. Aortic valve replacement in patients with aortic incompetence. Preoperative parameters influencing long-term results. Z Kardiol. 1986;75(suppl 2):146 54. 60. Taniguchi K, Nakano S, Hirose H, et al. Preoperative left ventricular func- tion: minimal requirement for successful late results of valve replacement for aortic regurgitation. J Am Coll Cardiol. 1987;10:510 8. 61. Turina J, Milincic J, Seifert B, et al. Valve replacement in chronic aortic regurgitation. True predictors of survival after extended follow-up. Circu- lation. 1998;98:II100 6. 62. Gaasch WH, Carroll JD, Levine HJ, et al. Chronic aortic regurgitation: prognostic value of left ventricular end-systolic dimension and end-dia- stolic radius/thickness ratio. J Am Coll Cardiol. 1983;1:775 82. 5. BICUSPID AORTIC VALVE 5.1. BAV and Associated Aortopathy 5.1.1. Diagnosis and Follow-Up of BAV 5.1.1.1. Diagnostic Testing: Initial Diagnosis 1. Masri A, Svensson LG, Griffin BP, et al. Contemporary natural his- tory of bicuspid aortic valve disease: a systematic review. Heart. 2017;103:1323 30. CLINICAL STATEMENTS AND GUIDELINES 2. Keane MG, Wiegers SE, Plappert T, et al. Bicuspid aortic valves are associ- ated with aortic dilatation out of proportion to coexistent valvular lesions. Circulation. 2000;102:III35 9. 3. Schaefer BM, Lewin MB, Stout KK, et al. The bicuspid aortic valve: an integrated phenotypic classification of leaflet morphology and aortic root shape. Heart. 2008;94:1634 8. of the thoracic aorta in adults: from the American Society of Echocardiogra- phy and the European Association of Cardiovascular Imaging: endorsed by the Society of Cardiovascular Computed Tomography and Society for Car- diovascular Magnetic Resonance. J Am Soc Echocardiogr. 2015;28:119 82. 5. Kang J-W, Song HG, Yang DH, et al. Association between bicuspid aortic valve phenotype and patterns of valvular dysfunction and bicuspid aor- topathy: comprehensive evaluation using MDCT and echocardiography. JACC Cardiovasc Imaging. 2013;6:150 61. 6. Kerstjens-Frederikse WS, Du Marchie Sarvaas GJ, Ruiter JS, et al. Left ven- tricular outflow tract obstruction: should cardiac screening be offered to first-degree relatives? Heart. 2011;97:1228 32. 7. Pachulski RT, Weinberg AL, Chan KL. Aortic aneurysm in patients with functionally normal or minimally stenotic bicuspid aortic valve. Am J Car- diol. 1991;67:781 2. 8. Hahn RT, Roman MJ, Mogtader AH, et al. Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves. J Am Coll Cardiol. 1992;19:283 8. 9. Nistri S, Sorbo MD, Marin M, et al. Aortic root dilatation in young men with normally functioning bicuspid aortic valves. Heart. 1999;82:19 22. 10. Novaro GM, Tiong IY, Pearce GL, et al. Features and predictors of ascend- ing aortic dilatation in association with a congenital bicuspid aortic valve. Am J Cardiol. 2003;92:99 101. knowledge gaps and rising to the challenge from the International Bicuspid Aortic Valve Consortium (BAVCon). Circulation. 2014;129:2691 704. 5.1.1.2. Diagnostic Testing: Routine Follow-Up 1. Masri A, Svensson LG, Griffin BP, et al. Contemporary natural history of bi- cuspid aortic valve disease: a systematic review. Heart. 2017;103:1323 30. 2. Ferencik M, Pape LA. Changes in size of ascending aorta and aortic valve function with time in patients with congenitally bicuspid aortic valves. Am J Cardiol. 2003;92:43 6. 3. Michelena HI, Khanna AD, Mahoney D, et al. Incidence of aortic complica- tions in patients with bicuspid aortic valves. JAMA. 2011;306:1104 12. 4. Davies RR, Goldstein LJ, Coady MA, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg. 2002;73:17 27. 5. Masri A, Kalahasti V, Alkharabsheh S, et al. Characteristics and long-term outcomes of contemporary patients with bicuspid aortic valves. J Thorac Cardiovasc Surg. 2016;151:1650 9.e1. 6. McKellar SH, Michelena HI, Li Z, et al. Long-term risk of aortic events fol- lowing aortic valve replacement in patients with bicuspid aortic valves. Am J Cardiol. 2010;106:1626 33. 7. Girdauskas E, Disha K, Borger MA, et al. Long-term prognosis of ascend- ing aortic aneurysm after aortic valve replacement for bicuspid versus tri- cuspid aortic valve stenosis. J Thorac Cardiovasc Surg. 2014;147:276 82. 8. Novaro GM, Griffin BP. Congenital bicuspid aortic valve and rate of as- cending aortic dilatation. Am J Cardiol. 2004;93:525 6. 9. Davies RR, Kaple RK, Mandapati D, et al. Natural history of ascending aortic aneurysms in the setting of an unreplaced bicuspid aortic valve. Ann Thorac Surg. 2007;83:1338 44. 10. Girdauskas E, Rouman M, Disha K, et al. The fate of mild-to-moderate proximal aortic dilatation after isolated aortic valve replacement for bicus- pid aortic valve stenosis: a magnetic resonance imaging follow-up study . Eur J Cardiothorac Surg. 2016;49:e80 6. 11. Borger MA, Fedak PWM, Stephens EH, et al. The American Associa- tion for Thoracic Surgery consensus guidelines on bicuspid aortic valve- related aortopathy: Full online-only version. J Thorac Cardiovasc Surg. 2018;156:e41 74. 5.1.2. Interventions for Patients With BAV 5.1.2.1. Intervention: Repair or Replacement of the Aorta 1. Masri A, Svensson LG, Griffin BP, et al. Contemporary natural history of bi- cuspid aortic valve disease: a systematic review. Heart. 2017;103:1323 30. 2. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/ SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular An- esthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Soci- ety for Vascular Medicine. J Am Coll Cardiol. 2010;55:e27 129. 3. Elefteriades JA. Natural history of thoracic aortic aneurysms: indica- tions for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg. 2002;74:S1877 80. 4. Davies RR, Goldstein LJ, Coady MA, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg. 2002;73:17 27. 5. Russo CF, Mazzetti S, Garatti A, et al. Aortic complications after bi- cuspid aortic valve replacement: long-term results. Ann Thorac Surg. 2002;74:S1773 6. 6. Borger MA, Preston M, Ivanov J, et al. Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease? J Thorac Cardiovasc Surg. 2004;128:677 83. 7. Svensson LG, Kim K-H, Blackstone EH, et al. Bicuspid aortic valve sur- gery with proactive ascending aorta repair. J Thorac Cardiovasc Surg. 2011;142:622 9, 9.9.e1 3. 8. Beckerman Z, Kayatta MO, McPherson L, et al. Bicuspid aortic valve repair in the setting of severe aortic insufficiency. J Vis Surg. 2018;4:101. 9. David TE, Feindel CM, David CM, et al. A quarter of a century of ex- perience with aortic valve-sparing operations. J Thorac Cardiovasc Surg. 2014;148:872 9. 10. Davies RR, Kaple RK, Mandapati D, et al. Natural history of ascending aortic aneurysms in the setting of an unreplaced bicuspid aortic valve. Ann Thorac Surg. 2007;83:1338 44. 11. Ergin MA, Spielvogel D, Apaydin A, et al. Surgical treatment of the dilated ascending aorta: when and how? Ann Thorac Surg. 1999;67:1834 9. 12. Svensson LG, Kim K-H, Lytle BW, et al. Relationship of aortic cross-sec- tional area to height ratio and the risk of aortic dissection in patients with bicuspid aortic valves. J Thorac Cardiovasc Surg. 2003;126:892 3. 13. Yasuda H, Nakatani S, Stugaard M, et al. Failure to prevent progressive dilation of ascending aorta by aortic valve replacement in patients with bicuspid aortic valve: comparison with tricuspid aortic valve. Circulation. 2003;108(suppl 1):II291 4. 14. Park CB, Greason KL, Suri RM, et al. Fate of nonreplaced sinuses of Valsalva in bicuspid aortic valve disease. J Thorac Cardiovasc Surg. 2011;142:278 84. 15. Svensson LG, Adams DH, Bonow RO, et al. Aortic valve and ascending aorta guidelines for management and quality measures. Ann Thorac Surg. 2013;95:S1 66. 5.1.2.2. Intervention: Repair or Replacement of the Aortic Valve 1. David TE, Feindel CM, David CM, et al. A quarter of a century of ex- perience with aortic valve-sparing operations. J Thorac Cardiovasc Surg. 2014;148:872 9. 2. Masri A, Kalahasti V, Alkharabsheh S, et al. Characteristics and long-term outcomes of contemporary patients with bicuspid aortic valves. J Thorac Cardiovasc Surg. 2016;151:1650 9.e1. 3. Schneider U, Feldner SK, Hofmann C, et al. Two decades of experience with root remodeling and valve repair for bicuspid aortic valves. J Thorac Cardiovasc Surg. 2017;153:S65 71. 4. Takagi H, Hari Y, Kawai N, et al. Meta-analysis of transcatheter aortic valve implantation for bicuspid versus tricuspid aortic valves. J Cardiol. 2019;74:40 8. 5. Kanjanahattakij N, Horn B, Vutthikraivit W, et al. Comparing outcomes after transcatheter aortic valve replacement in patients with stenotic bi- cuspid and tricuspid aortic valve: a systematic review and meta-analysis. Clin Cardiol. 2018;41:896 902. 6. Makkar RR, Yoon S-H, Leon MB, et al. Association between transcatheter aortic valve replacement for bicuspid vs tricuspid aortic stenosis and mor- tality or stroke. JAMA. 2019;321:2193 202. 7. Beckerman Z, Kayatta MO, McPherson L, et al. Bicuspid aortic valve repair in the setting of severe aortic insufficiency. J Vis Surg. 2018;4:101. 6. MITRAL STENOSIS 1. Eleid MF, Nishimura RA, Lennon RJ, et al. Left ventricular diastolic dys- function in patients with mitral stenosis undergoing percutaneous mitral balloon valvotomy. Mayo Clin Proc. 2013;88:337 44. CLINICAL STATEMENTS AND GUIDELINES 2. Nunes MCP, Tan TC, Elmariah S, et al. Net atrioventricular compliance is an independent predictor of cardiovascular death in mitral stenosis. Heart. 2017;103:1891 8. 3. Abramowitz Y, Jilaihawi H, Chakravarty T, et al. Mitral annulus calcifica- tion. J Am Coll Cardiol. 2015;66:1934 41. 4. Sud K, Agarwal S, Parashar A, et al. Degenerative mitral stenosis: unmet need for percutaneous interventions. Circulation. 2016;133:1594 604. 5. Bertrand PB, Mihos CG, Yucel E. Mitral annular calcification and calcific mitral stenosis: therapeutic challenges and considerations. Curr Treat Op- tions Cardiovasc Med. 2019;21:19. 6.1. Stages of MS 1. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10:1 25. 6.2. Rheumatic MS 6.2.1. Diagnosis and Follow-Up of Rheumatic MS 6.2.1.1. Diagnostic Testing: Initial Diagnosis 1. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10:1 25. 2. Nunes MCP, Tan TC, Elmariah S, et al. The echo score revisited: impact of incorporating commissural morphology and leaflet displacement to the prediction of outcome for patients undergoing percutaneous mitral valvu- loplasty. Circulation. 2014;129:886 95. 3. Cannan CR, Nishimura RA, Reeder GS, et al. Echocardiographic assess- ment of commissural calcium: a simple predictor of outcome after percu- taneous mitral balloon valvotomy. J Am Coll Cardiol. 1997;29:175 80. 4. Ellis K, Ziada KM, Vivekananthan D, et al. Transthoracic echocardiographic predictors of left atrial appendage thrombus. Am J Cardiol. 2006;97:421 5. 5. Kronzon I, Tunick PA, Glassman E, et al. Transesophageal echocardiogra- phy to detect atrial clots in candidates for percutaneous transseptal mitral balloon valvuloplasty. J Am Coll Cardiol. 1990;16:1320 2. 6. Tessier P, Mercier LA, Burelle D, et al. Results of percutaneous mitral commissurotomy in patients with a left atrial appendage thrombus de- tected by transesophageal echocardiography. J Am Soc Echocardiogr. 1994;7:394 9. 7. Gianstefani S, Monaghan MJ. Accurate assessment of the true mitral valve area in rheumatic mitral stenosis. Heart. 2013;99:219 21. 8. Min S-Y, Song J-M, Kim Y-J, et al. Discrepancy between mitral valve areas measured by two-dimensional planimetry and three-dimensional tran- soesophageal echocardiography in patients with mitral stenosis. Heart. 2013;99:253 8. 9. Nishimura RA, Rihal CS, Tajik AJ, et al. Accurate measurement of the transmitral gradient in patients with mitral stenosis: a simultaneous catheterization and Doppler echocardiographic study. J Am Coll Cardiol. 1994;24:152 8. 10. Abascal VM, Wilkins GT, O Shea JP, et al. Prediction of successful outcome in 130 patients undergoing percutaneous balloon mitral valvotomy. Circu- lation. 1990;82:448 56. 11. Wilkins GT, Weyman AE, Abascal VM, et al. Percutaneous balloon dilata- tion of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988;60:299 308. 12. Sutaria N, Northridge DB, Shaw TR. Significance of commissural calcifica- tion on outcome of mitral balloon valvotomy. Heart. 2000;84:398 402. 13. Gajjala OR, Durgaprasad R, Velam V, et al. New integrated approach to percutaneous mitral valvuloplasty combining Wilkins score with com- missural calcium score and commissural area ratio. Echocardiography. 2017;34:1284 91. 14. Thomas JD, Wilkins GT, Choong CY, et al. Inaccuracy of mitral pressure half-time immediately after percutaneous mitral valvotomy. Dependence on transmitral gradient and left atrial and ventricular compliance. Circula- tion. 1988;78:980 93. 6.2.1.3. Diagnostic Testing: Routine Follow-Up 1. Horstkotte D, Niehues R, Strauer BE. Pathomorphological aspects, aeti- ology and natural history of acquired mitral valve stenosis. Eur Heart J. 1991;12(suppl B):55 60. 2. Rinkevich D, Lessick J, Mutlak D, et al. Natural history of moderate mitral valve stenosis. Isr Med Assoc J. 2003;5:15 8. 3. Sagie A, Freitas N, Padial LR, et al. Doppler echocardiographic assessment of long-term progression of mitral stenosis in 103 patients: valve area and right heart disease. J Am Coll Cardiol. 1996;28:472 9. 6.2.1.4. Diagnostic Testing: Cardiac Catheterization 1. Nishimura RA, Rihal CS, Tajik AJ, et al. Accurate measurement of the transmitral gradient in patients with mitral stenosis: a simultaneous catheterization and Doppler echocardiographic study. J Am Coll Cardiol. 1994;24:152 8. 2. Gorlin R, Gorlin SG. Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves, and central circulatory shunts. I. Am Heart J. 1951;41:1 29. 3. Gorlin WB, Gorlin R. A generalized formulation of the Gorlin formula for calculating the area of the stenotic mitral valve and other stenotic cardiac valves. J Am Coll Cardiol. 1990;15:246 7. 6.2.1.5. Diagnostic Testing: Exercise Testing 1. Cheitlin MD. Stress echocardiography in mitral stenosis: when is it useful? J Am Coll Cardiol. 2004;43:402 4. 2. Cheriex EC, Pieters FA, Janssen JH, et al. Value of exercise Doppler-echocar- diography in patients with mitral stenosis. Int J Cardiol. 1994;45:219 26. 3. Grimaldi A, Olivotto I, Figini F, et al. Dynamic assessment of valvular reserve capacity in patients with rheumatic mitral stenosis. Eur Heart J Cardiovasc Imaging. 2012;13:476 82. 4. Suh WM, Kern MJ. Addressing the hemodynamic dilemma of combined mitral and aortic stenosis. Catheter Cardiovasc Interv. 2008;71:944 9. 5. Reis G, Motta MS, Barbosa MM, et al. Dobutamine stress echocardiog- raphy for noninvasive assessment and risk stratification of patients with rheumatic mitral stenosis. J Am Coll Cardiol. 2004;43:393 401. 6. Roshdy HS, Meshrif AM, El-Dosouky II. Value of the mitral valve resistance in evaluation of symptomatic patients with mild and moderate mitral ste- nosis a dobutamine stress echocardiographic study. Echocardiography. 2014;31:347 52. 6.2.2. Medical Therapy 1. Kim JY, Kim S-H, Myong J-P, et al. Outcomes of direct oral anticoagulants in patients with mitral stenosis. J Am Coll Cardiol. 2019;73:1123 31. 2. Giugliano RP, O Gara PT. DOACs in Patients with mitral stenosis and atrial fibrillation: time for a randomized clinical trial. J Am Coll Cardiol. 2019;73:1132 4. 3. Olesen KH. The natural history of 271 patients with mitral stenosis under medical treatment. Br Heart J. 1962;24:349 57. 4. Rowe JC, Bland EF, Sprague HB, et al. The course of mitral stenosis without surgery: ten- and twenty-year perspectives. Ann Intern Med. 1960;52:741 9. 5. Szekely P. Systemic embolism and anticoagulant prophylaxis in rheumatic heart disease. Br Med J. 1964;1:1209 12. 6. Wilson JK, Greenwood WF. The natural history of mitral stenosis. Can Med Assoc J. 1954;71:323 31. 7. Omran H, Rang B, Schmidt H, et al. Incidence of left atrial thrombi in patients in sinus rhythm and with a recent neurologic deficit. Am Heart J. 2000;140:658 62. 8. Yusuf J, Goyal M, Mukhopadhyay S, et al. Effect of heart rate control on coagulation status in patients of rheumatic mitral stenosis with atrial fibrillation a pilot study. Indian Heart J. 2015;67(suppl 2):S40 5. 9. Rigolin VH, Higgenbotham MB, Robiolio PA, et al. Effect of inadequate cardiac output reserve on exercise tolerance in patients with moderate mitral stenosis. Am J Cardiol. 1997;80:236 40. 10. Laufer-Perl M, Gura Y, Shimiaie J, et al. Mechanisms of effort intoler- ance in patients with rheumatic mitral stenosis: combined echocardiog- raphy and cardiopulmonary stress protocol. JACC Cardiovasc Imaging. 2017;10:622 33. 11. Kitzman DW, Upadhya B, Zhao D. New concepts in an old disease: exer- cise intolerance in moderate mitral stenosis. JACC Cardiovasc Imaging. 2017;10:634 6. 12. Saggu DK, Narain VS, Dwivedi SK, et al. Effect of ivabradine on heart rate and duration of exercise in patients with mild-to-moderate mitral steno- sis: a randomized comparison with metoprolol. J Cardiovasc Pharmacol. 2015;65:552 4. 13. Parakh N, Chaturvedi V, Kurian S, et al. Effect of ivabradine vs atenolol on heart rate and effort tolerance in patients with mild to moderate mitral stenosis and normal sinus rhythm. J Card Fail. 2012;18:282 8. CLINICAL STATEMENTS AND GUIDELINES 14. Agrawal V, Kumar N, Lohiya B, et al. Metoprolol vs ivabradine in patients with mitral stenosis in sinus rhythm. Int J Cardiol. 2016;221:562 6. 15. Rajesh GN, Sajeer K, Sajeev CG, et al. A comparative study of ivabradine and atenolol in patients with moderate mitral stenosis in sinus rhythm. Indian Heart J. 2016;68:311 5. 16. Iung B, Leenhardt A, Extramiana F. Management of atrial fibrillation in patients with rheumatic mitral stenosis. Heart. 2018;104:1062 8. 17. Krishnamoorthy KM. Incidence and predictors of left atrial thrombus in patients with rheumatic mitral stenosis and sinus rhythm: a transesopha- geal echocardiographic study. Echocardiography. 2012;29:876 7. 18. Manjunath CN, Srinivasa KH, Panneerselvam A, et al. Incidence and pre- dictors of left atrial thrombus in patients with rheumatic mitral stenosis and sinus rhythm: a transesophageal echocardiographic study. Echocar- diography. 2011;28:457 60. 19. Keenan NG, Cueff C, Cimadevilla C, et al. Usefulness of left atrial volume versus diameter to assess thromboembolic risk in mitral stenosis. Am J Cardiol. 2010;106:1152 6. 1. Nunes MCP, Tan TC, Elmariah S, et al. The echo score revisited: impact of incorporating commissural morphology and leaflet displacement to the prediction of outcome for patients undergoing percutaneous mitral valvu- loplasty. Circulation. 2014;129:886 95. 2. Bouleti C, Iung B, Laou nan C, et al. Late results of percutaneous mitral commissurotomy up to 20 years: development and validation of a risk score predicting late functional results from a series of 912 patients. Cir- culation. 2012;125:2119 27. 3. Meneguz-Moreno RA, Costa JR Jr, Gomes NL, et al. Very long term follow- up after percutaneous balloon mitral valvuloplasty. JACC Cardiovasc In- terv. 2018;11:1945 52. 4. Rifaie O, Abdel-Dayem MK, Ramzy A, et al. Percutaneous mitral valvoto- my versus closed surgical commissurotomy. Up to 15 years of follow-up of a prospective randomized study. J Cardiol. 2009;53:28 34. 5. Cardoso LF, Grinberg M, Pomerantzeff PMA, et al. Comparison of open commissurotomy and balloon valvuloplasty in mitral stenosis. A five-year follow-up. Arq Bras Cardiol. 2004;83:248 52; 3 7. 6. Cotrufo M, Renzulli A, Ismeno G, et al. Percutaneous mitral commissur- otomy versus open mitral commissurotomy: a comparative study. Eur J Cardiothorac Surg. 1999;15:646 51. 7. Song J-K, Kim M-J, Yun S-C, et al. Long-term outcomes of percutaneous mitral balloon valvuloplasty versus open cardiac surgery. J Thorac Cardio- vasc Surg. 2010;139:103 10. 8. Arora R, Nair M, Kalra GS, et al. Immediate and long-term results of bal- loon and surgical closed mitral valvotomy: a randomized comparative study. Am Heart J. 1993;125:1091 4. 9. Ben FM, Ayari M, Maatouk F, et al. Percutaneous balloon versus surgical closed and open mitral commissurotomy: seven-year follow-up results of a randomized trial. Circulation. 1998;97:245 50. 10. Patel JJ, Shama D, Mitha AS, et al. Balloon valvuloplasty versus closed commissurotomy for pliable mitral stenosis: a prospective hemodynamic study. J Am Coll Cardiol. 1991;18:1318 22. 11. Reyes VP, Raju BS, Wynne J, et al. Percutaneous balloon valvuloplasty com- pared with open surgical commissurotomy for mitral stenosis. N Engl J Med. 1994;331:961 7. 12. Turi ZG, Reyes VP, Raju BS, et al. Percutaneous balloon versus surgical closed commissurotomy for mitral stenosis. A prospective, randomized trial. Circulation. 1991;83:1179 85. 13. Reichart DT, Sodian R, Zenker R, et al. Long-term ( 50 years) results of patients after mitral valve commissurotomy a single-center experience. J Thorac Cardiovasc Surg. 2012;143:S96 8. 14. Yang B, DeBenedictus C, Watt T, et al. The impact of concomitant pulmo- nary hypertension on early and late outcomes following surgery for mitral stenosis. J Thorac Cardiovasc Surg. 2016;152:394 400.e1. 15. Demirkan B, Guray Y, Guray U, et al. The acute effect of percutaneous mitral balloon valvuloplasty on atrial electromechanical delay and P-wave dispersion in patients with mitral stenosis. Herz. 2013;38:210 5. 16. Aviles RJ, Nishimura RA, Pellikka PA, et al. Utility of stress Doppler echocar- diography in patients undergoing percutaneous mitral balloon valvotomy. J Am Soc Echocardiogr. 2001;14:676 81. 17. Bouleti C, Iung B, Himbert D, et al. Relationship between valve calcifica- tion and long-term results of percutaneous mitral commissurotomy for rheumatic mitral stenosis. Circ Cardiovasc Interv. 2014;7:381 9. 18. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10:1 25. 19. Cannan CR, Nishimura RA, Reeder GS, et al. Echocardiographic assess- ment of commissural calcium: a simple predictor of outcome after percu- taneous mitral balloon valvotomy. J Am Coll Cardiol. 1997;29:175 80. 20. Apostolakis EE, Baikoussis NG. Methods of estimation of mitral valve re- gurgitation for the cardiac surgeon. J Cardiothorac Surg. 2009;4:34. 21. Badheka AO, Shah N, Ghatak A, et al. Balloon mitral valvuloplasty in the United States: a 13-year perspective. Am J Med. 2014;127:1126 e1 12. 22. Abascal VM, Wilkins GT, O Shea JP, et al. Prediction of successful outcome in 130 patients undergoing percutaneous balloon mitral valvotomy. Circu- lation. 1990;82:448 56. 23. Wilkins GT, Weyman AE, Abascal VM, et al. Percutaneous balloon dilata- tion of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988;60:299 308. 24. Sutaria N, Northridge DB, Shaw TR. Significance of commissural calcifica- tion on outcome of mitral balloon valvotomy. Heart. 2000;84:398 402. 25. Gajjala OR, Durgaprasad R, Velam V, et al. New integrated approach to percutaneous mitral valvuloplasty combining Wilkins score with com- missural calcium score and commissural area ratio. Echocardiography. 2017;34:1284 91. 26. Cho I-J, Hong G-R, Lee SH, et al. Differences in characteristics, left atrial reverse remodeling, and functional outcomes after mitral valve replace- ment in patients with low-gradient very severe mitral stenosis. J Am Soc Echocardiogr. 2016;29:759 67. 27. El Sabbagh A, Reddy YNV, Barros-Gomes S, et al. Low-gradient severe mi- tral stenosis: hemodynamic profiles, clinical characteristics, and outcomes. J Am Heart Assoc. 2019;8:e010736. 28. Nunes MCP, Tan TC, Elmariah S, et al. Net atrioventricular compliance is an independent predictor of cardiovascular death in mitral stenosis. Heart. 2017;103:1891 8. 29. Eleid MF, Nishimura RA, Lennon RJ, et al. Left ventricular diastolic dys- function in patients with mitral stenosis undergoing percutaneous mitral balloon valvotomy. Mayo Clin Proc. 2013;88:337 44. 30. Cho I-J, Chang H-J, Lee SY, et al. Differential impact of net atrioventricular compliance on clinical outcomes in patients with mitral stenosis according to cardiac rhythm. J Am Soc Echocardiogr. 2017;30:552 60. 31. Ellis LB, Singh JB, Morales DD, et al. Fifteen-to twenty-year study of one thousand patients undergoing closed mitral valvuloplasty. Circulation. 1973;48:357 64. 32. Finnegan JO, Gray DC, MacVaugh H 3rd, et al. The open approach to mitral commissurotomy. J Thorac Cardiovasc Surg. 1974;67:75 82. 33. Gross RI, Cunningham JN Jr, Snively SL, et al. Long-term results of open radical mitral commissurotomy: ten year follow-up study of 202 patients. Am J Cardiol. 1981;47:821 5. 34. Halseth WL, Elliott DP, Walker EL, et al. Open mitral commissurotomy. A modern re-evaluation. J Thorac Cardiovasc Surg. 1980;80:842 8. 35. John S, Bashi VV, Jairaj PS, et al. Closed mitral valvotomy: early results and long-term follow-up of 3724 consecutive patients. Circulation. 1983;68:891 6. 36. Mullin MJ, Engelman RM, Isom OW, et al. Experience with open mitral commissurotomy in 100 consecutive patients. Surgery. 1974;76:974 82. 37. Song H, Kang D-H, Kim JH, et al. Percutaneous mitral valvuloplasty versus surgical treatment in mitral stenosis with severe tricuspid regurgitation. Circulation. 2007;116:I246 50. 38. Hart SA, Krasuski RA, Wang A, et al. Pulmonary hypertension and elevat- ed transpulmonary gradient in patients with mitral stenosis. J Heart Valve Dis. 2010;19:708 15. 39. Coutinho GF, Antunes MJ. Surgery for mitral stenosis in patients with pulmonary hypertension: how far can we go? J Thorac Cardiovasc Surg. 2016;152:302 3. 40. Mahfouz RA. Impact of pulmonary artery stiffness on right ventricular function and tricuspid regurgitation after successful percutaneous balloon mitral valvuloplasty: the importance of early intervention. Echocardiogra- phy. 2012;29:1157 63. 41. Arat N, Altay H, Korkmaz S, et al. The effect of baseline pulmonary artery pressure on right ventricular functions after mitral balloon valvuloplasty for rheumatic mitral stenosis: a tissue Doppler imaging study. Turk Kardi- yol Dern Ars. 2008;36:223 30. 42. Vincens JJ, Temizer D, Post JR, et al. Long-term outcome of cardiac surgery in patients with mitral stenosis and severe pulmonary hypertension. Circu- lation. 1995;92:II137 42. 43. Iung B, Leenhardt A, Extramiana F. Management of atrial fibrillation in patients with rheumatic mitral stenosis. Heart. 2018;104:1062 8. 44. Cheitlin MD. Stress echocardiography in mitral stenosis: when is it useful? J Am Coll Cardiol. 2004;43:402 4. CLINICAL STATEMENTS AND GUIDELINES 45. Cheriex EC, Pieters FA, Janssen JH, et al. Value of exercise Doppler-echocar- diography in patients with mitral stenosis. Int J Cardiol. 1994;45:219 26. 46. Grimaldi A, Olivotto I, Figini F, et al. Dynamic assessment of valvular reserve capacity in patients with rheumatic mitral stenosis. Eur Heart J Cardiovasc Imaging. 2012;13:476 82. 47. Suh WM, Kern MJ. 