Update on TAVI Indications From 2020 ACC/AHA Valvular Guidelines

Sundt TM, Jneid H.
Guideline Update on Indications for Transcatheter Aortic Valve Implantation Based on the 2020 American College of Cardiology/American Heart Association Guidelines for Management of Valvular Heart Disease. JAMA Cardiol 2021;Jul 21:[Epub ahead of print].

The following are key points to remember from this guideline synopsis of the 2020 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Management of Valvular Heart Disease:

  1. The decision to treat severe aortic stenosis (AS) with surgical aortic valve replacement (SAVR) versus transcatheter aortic valve implantation (TAVI) must take into account patient factors (e.g., age, comorbidities, life expectancy, patient preference), procedural factors (e.g., anticipated perioperative/procedural risk, anatomy, operator/institutional experience), and prosthesis factors (e.g., mechanical vs. tissue, durability). Shared decision making and the multidisciplinary Heart Team evaluation are vital to this process.
  2. The data underpinning recommendations for SAVR versus TAVI (with transfemoral approach) in the updated 2020 ACC/AHA Guidelines for the Management of Valvular Heart Disease included multiple randomized controlled trials (RCTs) and large registry data, with Level of Evidence A for five of the eight Class I recommendations for the treatment of severe AS with SAVR versus TAVI.
  3. TAVI is favored in older patients (over 80 years old) of any surgical risk category with life expectancy <10 years, and in older patients at high or prohibitive risk for mortality from SAVR with life expectancy of ≥1 year.
  4. SAVR is favored in younger patients (<65 years old) with life expectancy >20 years; in asymptomatic patients with severe AS who have other indications for intervention (e.g., abnormal exercise test, very severe AS, rapid progression, elevated brain natriuretic peptide); and in those whose anatomy, especially iliofemoral vascular access, is unsuitable for TAVI.
  5. SAVR or TAVI can be considered for symptomatic patients between the ages of 65 and 80 years, and in asymptomatic patients <80 years with ejection fraction <50%.
  6. There are patients with severe symptomatic AS who will have life expectancy <1 year. In these cases, careful discussion regarding benefits and risks, determining patient values, shared decision making, and involvement of the Palliative Care team is important.
  7. As patients <65 years old and those with bicuspid aortic valve (BAV) were not included in the RCTs, the ACC/AHA guideline recommendations cannot be used to recommend TAVI in these patients, and the Heart Team evaluation is crucial in determining the appropriateness of TAVI.
  8. TAVI does not address concomitant coronary artery disease or aortopathy and may not impact clinically significant mitral or tricuspid valve disease or atrial fibrillation, all of which can be addressed surgically.
  9. TAVI valve durability data are established out to 5 years, but more time is needed to determine whether durability will extend to 10 or more years. The guidelines take this into careful account with the age ranges in the recommendations.
  10. Future study will need to focus on need for and outcomes of operation after TAVI explantation (e.g., for structural valve degeneration, infection, device failure, patient–prosthesis mismatch).

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease

Keywords: Aortic Valve Stenosis, Atrial Fibrillation, Cardiac Surgical Procedures, Coronary Artery Disease, Exercise Test, Geriatrics, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Life Expectancy, Palliative Care, Risk Assessment, Stroke Volume, Transcatheter Aortic Valve Replacement, Tricuspid Valve

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