American Board of Internal Medicine (ABIM) Certification Practice Exam

What is a severe indicator for aortic valve replacement, even in asymptomatic patients?

1. Severe aortic regurgitation

2. Very severe aortic stenosis

3. Moderate aortic stenosis

4. Mild aortic regurgitation

The correct answer is: Very severe aortic stenosis

The indication for aortic valve replacement in asymptomatic patients is particularly relevant for very severe aortic stenosis. This condition is characterized by a marked decrease in the valve area and significant hemodynamic implications, even in the absence of symptoms. Guidelines typically recommend surgical intervention in asymptomatic individuals when the aortic stenosis is classified as very severe, defined by a valve area of less than 1.0 cm² or a peak aortic jet velocity greater than 4.0 m/s, especially if there is evidence of left ventricular dysfunction or other parameters that suggest a poorer prognosis. In severe aortic regurgitation, while surgery is warranted, the need may not arise until symptoms develop or there are signs of left ventricular dilation or dysfunction. Moderate aortic stenosis generally does not warrant surgical intervention unless symptoms are present or there are concerning changes in cardiac function. Mild aortic regurgitation typically does not require surgical intervention and is often managed conservatively. Thus, the necessity for aortic valve replacement in asymptomatic patients is particularly emphasized for those with very severe aortic stenosis due to its potential to lead to significant morbidity and mortality if left untreated.