<prompt> A 50-year-old man with aortic stenosis is doing exercise for 11 minutes according to Bruce protocol. Exercise had to be stopped due to fatigue. He had a peak sytolic gradient of 60 mmHg across the aortic valve at rest. What is the best management for this patient?Medical managementAortic valve replacementAortic valve balloon dilatation to prevent further worseningCoronary angiography  <response>: Ans. b a Aortic valve replacement Medical Management Ref: ACCAHA guidelines; European Cardiology Society Guidelines: http: circ. ahajountals.org content 12217 1734.full.pdfhtml; Braunwalds Heart Disease: 9e p1474The patient in question has asymptomatic aortic stenosis but develops symptoms on exercise abnormalpositive exercise test. Also the presence of mean pressure gradient of 60mm Hg put this patient into the category of Very Severe Aortic Stenosis or Critical Aortic Stenosis.Optimal management of asymptomatic severe Aortic Stenosis continues to be a source of ongoing clinical controversy. Surgical Aortic Valve Replacement and Watchful 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 Aortic Valve Replacement AVR.50-year-old patient with Asymptomatic Severe Aortic StenosisPositive Exercise Stress TestMean Pressure Gradient 60 mm HgSymptoms during exercise such as dyspnea, angina, and syncope or near syncope constitute positive criteria indicating an abnormal stress test in patients with asymptomatic aortic stenosis.Mean pressure gradient 60 mm Hg and or aortic valve area 0.6 cm2 and or aortic jet velocity 5.0 m per second is classified as Extremely Severe Aortic Stenosis Critical Aortic StenosisSevere aortic stenosis with an abnormal response to exercise is considered a Class lIb indication for aortic valve replacement according to the ACCAHA Guidelines. Severe aortic stenosis with an abnormal response to exercise is considered a Class IC indication for aortic valve replacement according to European Cardiology Society Guidelines ECS GuidelinesExtremely severe aortic stenosis mean gradient 60 mm Hg is considered a class lIb indication for aortic valve replacement according to the ACCAHA Guidelines. Indications of AVR in Asymptomatic Severe Aortic StenosisClass IClass lIb Patients undergoing cardiac surgery for other indications Coronary artery bypass graft surgery or aortic surgery Left ventricular ejection fraction _50 Abnormal hemodynamic response to exercise Symptoms or asymptomatic hypotension High probability of rapid progression Age, Calcification, Concomitant CAD Asymptomatic very severe AS 