2017 AUC for Management of Severe Aortic Stenosis

Authors:
Bonow RO, Brown AS, Gillam LD, et al.
Citation:
ACC/AATS/AHA/ASE/EACTS/HVS/SCA/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for the Treatment of Patients With Severe Aortic Stenosis: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017;Oct 17:[Epub ahead of print].

This multisocietal collaborative document is the first of its kind to address Appropriate Use Criteria (AUC) for the Treatment of Patients With Severe Aortic Stenosis (AS). The following are key points to remember:

  1. Asymptomatic patients with high-gradient severe AS:
    • No intervention is appropriate or intervention may be considered for those with left ventricular ejection fraction (LVEF) ≥50%, Vmax 4.0-4.9 m/s, negative exercise stress, and no predictors of rapid progression.
    • Intervention is appropriate or no intervention may be considered for those with a high-risk profession or lifestyle and low surgical risk, or for those with a predictor of rapid progression. Intervention is appropriate for those with very severe AS (Vmax ≥5.0 m/s or mean gradient ≥60 mm Hg) and low surgical risk, and is appropriate or may be considered for those at intermediate or high surgical risk.
    • Intervention is appropriate for patients with an abnormal exercise test, LVEF <50%, or when undergoing another cardiac surgical procedure.
  2. Low-flow (LF) low-gradient (LG) severe AS and reduced LVEF (<50%):
    • Intervention is appropriate for patients with LFLG severe AS and LVEF 20-49% with flow reserve on low-dose dobutamine stress echocardiography (DSE); intervention is appropriate or balloon aortic valvotomy (BAV) or no intervention may be considered for patients with no flow reserve, but with a very calcified aortic valve suggestive of truly severe AS.
    • For patients with LVEF <20%, intervention is appropriate or BAV may be considered for patients with severe high-gradient AS, or for patients with LFLG AS and flow reserve on DSE.
    • Intervention is inappropriate for patients with pseudo-severe AS; or for patients with LVEF <20%, mean gradient <20 mm Hg, and no flow reserve on DSE.
  3. LG severe AS and preserved LVEF (≥50%):
    • Intervention is appropriate for patients with LFLG severe AS, severe aortic valve calcification, and symptoms referable to AS.
    • Intervention is appropriate for patients with normal flow (NF) LG AS, severe aortic valve calcification, and symptoms referable to AS.
  4. Symptomatic severe AS and high or extreme surgical risk:
    • For symptomatic patients with Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) 8-15% due to multiple comorbidities, transcatheter aortic valve replacement (TAVR) is appropriate and surgical AVR (SAVR) may be reasonable if anticipated life expectancy is >1 year; neither TAVR nor SAVR is reasonable if anticipated life expectancy is <1 year.
    • For patients with STS-PROM >15% due to multiple comorbidities, TAVR is appropriate if health status appears influenced more by AS than by comorbidities and anticipated life expectancy is >1 year.
    • For patients with STS-PROM 8-15% due to frailty with symptoms of fatigue but no chest pain, syncope, or shortness of breath, TAVR is appropriate if B-type natriuretic peptide (BNP) is elevated or if AS is very severe (Vmax ≥5 m/s).
    • TAVR is appropriate for patients with severe symptomatic AS and porcelain aorta or hostile chest.
  5. Symptomatic severe high-gradient AS with associated coronary artery disease (CAD):
    • For patients with 1- or 2-vessel CAD, SAVR + coronary artery bypass grafting (CABG) is appropriate for low, intermediate, or high surgical risk; TAVR + percutaneous coronary intervention (PCI) is appropriate for patients at intermediate or high surgical risk; and SAVR + PCI may be appropriate in the absence of proximal left anterior descending artery (LAD) involvement.
    • For patients with 3-vessel CAD, SAVR + CABG is appropriate for low, intermediate, or high surgical risk and regardless of SYNTAX score; and TAVR + PCI is appropriate for patients at intermediate or high surgical risk and SYNTAX score <22.
    • For patients with left main CAD, SAVR + CABG is appropriate for low, intermediate, or high surgical risk and regardless of SYNTAX score; TAVR + PCI is appropriate for patients at intermediate or high surgical risk and SYNTAX score <33; and TAVR + PCI may be appropriate for patients at intermediate or high surgical risk and SYNTAX score ≥33.
  6. Symptomatic severe AS with another valve or ascending aorta pathology:
    • SAVR + surgical mitral intervention is appropriate for patients at low, intermediate, or high surgical risk in the settings of severe primary mitral regurgitation (MR) or severe secondary MR. Either SAVR + surgical mitral intervention or TAVR + percutaneous balloon mitral valvotomy (PBMV) is appropriate in the setting of severe rheumatic MS with no contraindication to PMBV and high surgical risk.
    • SAVR + surgical tricuspid valve intervention is appropriate for patients at intermediate surgical risk with severe secondary tricuspid regurgitation and dilated right ventricular (RV) or tricuspid annulus, but minimal pulmonary hypertension (PH) regardless of RV systolic function. TAVR alone is appropriate for patients at high surgical risk with severe secondary tricuspid regurgitation and dilated RV or tricuspid annulus, with severe PH and moderate to severe RV dysfunction; in the same patients, SAVR + tricuspid valve surgery may be appropriate.
    • SAVR + ascending aorta repair is appropriate for patients with bicuspid valve and ascending aorta ≥4.5 cm at low, intermediate, or high surgical risk; SAVR alone is appropriate for patients with bicuspid valve and ascending aorta <4.5 cm at low, intermediate, or high surgical risk; TAVR alone may be appropriate in patients with bicuspid valve at high surgical risk regardless of aorta size.
    • SAVR + myectomy is appropriate and SAVR alone may be appropriate for patients with prominent basal septal hypertrophy with outflow tract narrowing and flow acceleration at low, intermediate, or high surgical risk; TAVR alone may be appropriate for patients at high or intermediate surgical risk.
  7. Severe or critical AS and major noncardiac surgery:
    • For symptomatic patients with severe AS undergoing elective or urgent major noncardiac surgery, aortic valve intervention is appropriate, and BAV may be considered.
    • For asymptomatic patients with severe AS and no evidence of LV decompensation undergoing elective major noncardiac surgery, aortic valve intervention is appropriate, and no intervention may be considered.
    • For asymptomatic patients with severe AS and no evidence of LV decompensation undergoing urgent major noncardiac surgery, aortic valve intervention, no intervention, or BAV may be considered.
  8. Aortic bioprosthesis with structural valve degeneration and severe symptomatic AS or aortic regurgitation:
    • SAVR or TAVR is appropriate in patients at intermediate or high surgical risk and bioprosthesis size ≥23 mm.
    • SAVR is appropriate and TAVR may be appropriate in patients at intermediate or high surgical risk and bioprosthesis size 21 mm.
    • SAVR is appropriate and TAVR may be appropriate in patients at high surgical risk and bioprosthesis size ≤19 mm; SAVR is appropriate (and TAVR is not appropriate) in patients at intermediate risk and bioprosthesis size ≤19 mm.

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