Valvular heart disease: a perspective on the asymptomatic patient with severe valvular aortic stenosis.

Early in 2006, the European Society of Cardiology (ESC) assigned the 2006 Denolin lecturer to provide a broad perspective on the asymptomatic patient with severe calcific valvular aortic stenosis (AS) in the older patient. Subsequently, in late 2006, American College of Cardiology/American Heart Association Guidelines and in 2007 ESC Guidelines have given the Class I recommendation to 'primary' aortic valve replacement (AVR) for asymptomatic patients with AS only to those with left ventricular dysfunction at rest and to those who only become symptomatic on exercise testing. Indications for AVR in classes IIa and IIb were provided. However, almost all of the recommendations in classes I and II were based on level of evidence C. 'Primary' AVR is that which is recommended for severe AS as opposed to AVR secondary to surgery for other cardiovascular disease.