2012 ACCF/AATS/SCAI/STS Expert Consensus Document on Transcatheter Aortic Valve Replacement
The following are 10 points to remember about this expert consensus document:
1. Transcatheter aortic valve replacement (TAVR) offers new and potentially transformational technology for patients with severe aortic valvular stenosis who are either extremely high-risk candidates, inoperable for surgical aortic valve replacement (AVR), or inoperable by virtue of associated comorbidities.
2. The implementation of TAVR into the flow of patient care is complex, involving consideration of several key factors such as clinical site selection, operator and team training and experience, patient selection and evaluation, procedural performance and complication management, and postprocedural care.
3. Currently, surgical AVR is the only effective treatment considered a Class I recommendation by American College of Cardiology Foundation/American Heart Association (ACCF/AHA) and European Society of Cardiology (ESC) guidelines in adults with severe symptomatic aortic stenosis (AS).
4. TAVR is recommended in patients with severe, symptomatic, calcific stenosis of a trileaflet aortic valve who have aortic and vascular anatomy suitable for TAVR and a predicted survival >12 months, and who have a prohibitive surgical risk as defined by an estimated 50% or greater risk of mortality or irreversible morbidity at 30 days or other factors such as frailty, prior radiation therapy, porcelain aorta, and severe hepatic or pulmonary disease. TAVR is also a reasonable alternative to surgical AVR in patients at high surgical risk (PARTNER [Placement of AoRtic TraNscathetER Valve] trial criteria: Society of Thoracic Surgeons [STS] ≥8%).
5. Registry data suggest that in high-risk patients, TAVR may be deployed with a high degree of procedural success, predictable risk of stroke, device-dependent high risk of pacemaker implantation (particularly with CoreValve), and a 30-day mortality rate that seems potentially acceptable in a debilitated and ill patient population. Importantly, TAVR seems to alleviate AS to a similar degree as surgical AVR, and patients tend to return to Class I or II symptoms with substantial improvements in quality of life.
6. The benefit from TAVR in inoperable patients with symptomatic severe AS greatly exceeded the risk in the PARTNER trial. In the high-risk cohort A patients, TAVR was noninferior to AVR for all-cause mortality at 1 year.
7. A patient-centric educational effort is essential in providing the patient and family information to facilitate interaction with the health care team, and promote personalized decision making for each patient prior to TAVR. The creation of a multidisciplinary team that includes the patient in the decision process in choosing the most appropriate form of treatment for AS including AVR (i.e., surgical or percutaneous) is essential.
8. TAVR is typically performed under general anesthesia with central monitoring, using a pulmonary artery catheter and transesophageal echocardiography.
9. The noncompliant hypertrophied ventricles in these patients are very susceptible to myocardial ischemia. The combination of anesthesia, rapid pacing, volume shifts, and brief periods of no cardiac output have made hemodynamic shock and low cardiac output a not infrequent occurrence during and immediately after TAVR.
10. The long-term care of the patient after TAVR will be mainly guided by the primary referring cardiologist. In contrast to patients undergoing surgical AVR, patients undergoing TAVR tend to be older, with more severe comorbidities and lower functional status, mandating more frequent cardiology follow-up.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Aortic Surgery, Cardiac Surgery and Heart Failure, Interventions and Imaging, Echocardiography/Ultrasound, Hypertension
Keywords: Heart Valve Prosthesis, Myocardial Ischemia, Stroke, Dental Porcelain, Blood Pressure, Heart Valve Prosthesis Implantation, Catheterization, Swan-Ganz, Hemodynamics, Cardiac Output, Low, Quality of Life, Hypertension, United States, Echocardiography, Transesophageal, Lung Diseases, Transcatheter Aortic Valve Replacement
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