First Appropriate Use Criteria for Treatment of Severe Aortic Stenosis Published

The first Appropriate Use Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS), developed by the ACC in collaboration with several other cardiovascular societies, was published Oct. 17 in the Journal of the American College of Cardiology.

The AUC writing group identified 95 clinical scenarios and up to six potential treatment options. The rating panel categorized treatment options for each clinical scenario as Appropriate, May Be Appropriate, or Rarely Appropriate. The panel determined that either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) is Appropriate for most intermediate or high surgical risk patients with symptomatic AS. Guidance is also provided for cases in which the appropriate intervention is less clear.

The AUC are presented in seven tables of clinical scenarios. The first table focuses on patients with high gradients (Stages C1 and C2) and does not differentiate between SAVR and TAVR. Instead, the primary decision is between aortic valve replacement (AVR) and no intervention. In these scenarios, stress testing is key for decision making.

The second table addresses criteria for distinguishing severe and pseudosevere AS. The AUC do not differentiate between SAVR and TAVR, but whether an intervention is appropriate. The cut-points for flow, gradient and ejection fraction are the same as those in most guidelines. Balloon aortic valvuloplasty (BAV) is rated as Rarely Appropriate except in intermediate to high-risk patients in whom the potential clinical benefit of AVR is uncertain, and should not be used for palliation.

The third table focuses on the appropriateness of SAVR or TAVR in patients with symptomatic severe AS (high or extreme surgical risk). BAV is offered as a palliative intervention or bridge to decision making. Details are provided to assist in assessment of risk versus benefit of interventions.

The fourth table presents AUC for patients with severe symptomatic AS with associated unrevascularized stable coronary artery disease. The scenarios are based on anatomical characterization. TAVR or SAVR with or without percutaneous coronary intervention and SAVR plus coronary artery bypass graft are recommended for these patients, depending on the clinical scenario.

The fifth table focuses on common scenarios in patients with severe symptomatic AS and other valve or ascending aortic pathology that may present clinical decision making challenges. The table lists six possible treatment options, depending on the specifics of each clinical scenario.

The appropriateness of aortic valve intervention to reduce the risk of major noncardiac surgery in patients with hemodynamically severe AS is addressed in the sixth table. The main issues for managing these patients are whether major noncardiac surgery is elective or urgent and whether the severe AS is symptomatic or asymptomatic.

The seventh table focuses on patients who are symptomatic due to failing aortic bioprostheses. Although surgery has been the only treatment option in this scenario, some transcatheter valve technologies have recently been approved for high or extremely high surgical risk patients.

This AUC report is intended to inform decision making, improve the quality of patient care and assist education initiatives. The authors emphasize the importance of clinical judgement and practice experience in determining the best options for individual patients. “As advances in technology and evidence-based medicine occur rapidly, and future studies of implementation of these criteria for severe AS are conducted, we expect further areas of exploration and elaboration to be identified,” the authors concluded.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease

Keywords: Aortic Valve, Bioprosthesis, Transcatheter Aortic Valve Replacement, Coronary Artery Disease, Stroke Volume, Area Under Curve, Aortic Valve Stenosis, Heart Valve Prosthesis, Coronary Artery Bypass, Percutaneous Coronary Intervention, Patient Care, Decision Making, Evidence-Based Medicine

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