ACC Expert Consensus on TAVR for Adults With Aortic Stenosis
- Otto CM, Kumbhani DJ, Alexander KP, et al.
- 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults With Aortic Stenosis: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2017;Jan 4:[Epub ahead of print].
Transcatheter aortic valve replacement (TAVR) is a new and transformational technology for patients with severe aortic stenosis (AS). Although currently approved for use in intermediate to high surgical risk or inoperable patients, it is likely that it will be utilized in progressively lower-risk patients. Starting from the point where a patient with severe AS is found to have an indication for AVR, this clinical expert consensus pathway is intended to provide additional detail and practical guidance about TAVR, with point-of-care checklists and algorithms separated into four sections: 1) preprocedure evaluation, 2) imaging modalities and measurements, 3) key issues in performing the procedure, and 4) recommendations for patient follow-up after TAVR. The following are points to remember:
- Assumptions made for this document include the following:
- Patients considered for TAVR should have severe symptomatic AS (stage D valve disease), as defined by the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for Management of Patients With Valvular Heart Disease.
- Patients considered for TAVR should be adults with calcific valvular AS.
- Consideration for TAVR necessitates the assessment of underlying risk for surgical AVR (SAVR) using risk stratification based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease, with an integrated assessment that combines the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score (low risk [<4%], intermediate risk [4-8%], or high risk [>8%]), frailty, organ system dysfunction, and procedure-specific impediments.
- A Heart Valve Team will be involved with all aspects of the decision-making and delivery of this complex technology.
- Pre-TAVR selection and evaluation:
- Shared decision-making. The management of patients who are being considered for TAVR is best achieved by a multidisciplinary, collaborative Heart Valve Team that includes cardiologists with expertise in heart valve disease, structural interventional cardiologists, imaging specialists, cardiovascular surgeons, cardiovascular anesthesiologists, and cardiovascular nursing professionals.
- Initial assessment. Initial assessment includes evaluation of AS symptoms and disease severity, standard clinical data, and determination of major cardiovascular and noncardiovascular comorbidities.
- Functional assessment. Comprehensive functional assessment should include assessment of frailty, physical function, and cognitive function. In addition, assessment of futility (life expectancy of <1 year despite a successful procedure, chance of “survival with benefit” <25% at 2 years) is appropriate.
- Risk categories. Assessment of risk in patients referred for TAVR should include the STS risk estimate; and assessment of frailty, major organ system dysfunction, and procedure-specific impediments. In addition to STS-PROM scores defining low, intermediate, and high risk, prohibitive risk is defined as risk of mortality and morbidity at 1 year >50%, compromise of ≥3 major organ systems, severe frailty, or severe procedure-specific impediments.
- Integrated risk-benefit assessment. The final treatment decision should be individualized, and based on clinical and imaging evaluation, risk assessment, the patient’s goals and expectations, and futility considerations.
- TAVR imaging and assessment:
- General principles and technical considerations. Initial assessment and staging of AS severity is best performed with transthoracic echocardiography (TTE); multimodality imaging is needed for preprocedural planning and intraoperative decision-making given the complex 3D anatomy of the aortic valve, sinuses, and annulus.
- Preprocedural evaluation. Preprocedural evaluation should include assessment of aortic valve morphology (number of leaflets, assessment of calcification and leaflet motion), aortic valve function (severity of AS), left ventricular geometry, annular sizing, and aortic root measurements. Vascular imaging of the entire thoracoabdominal aorta, the major thoracic arterial vasculature, carotids, and iliofemoral vasculature is critical because of the large size of delivery sheaths.
- Periprocedural evaluation. Multi-detector computed tomography (MDCT) can assist with predicting the optimal delivery angle, and for confirming annular sizing. Deployment is done under fluoroscopy, although transesophageal echocardiography (TEE) is an alternate approach. Among patients undergoing general anesthesia, TEE is useful for assessment of valve placement, central and paravalvular aortic regurgitation (AR), immediate assessment of gradients, and procedural complications. There may be an expanding role for periprocedural TTE instead of TEE.
- Long- term post-procedural evaluation. Echocardiography is recommended to evaluate the valve postprocedurally. MDCT can be used to evaluate valve anatomy and to evaluate for valve thrombosis. CMR can be used in conjunction with TTE for the quantification of AR.
- TAVR procedure:
- Preprocedural planning. Preprocedural planning should include valve choice, vascular access, procedure location, anesthetic considerations, and anticipated management of potential complications.
- Procedural details. Procedural details include anesthesia administration, vascular access, assessment of optimal fluoroscopic views for device deployment, anticoagulation, possible annular predilation, valve delivery and deployment, and post-deployment valve assessment.
- Post-TAVR clinical management:
- Immediate post-procedure management. Management immediately after TAVR deployment includes waking from sedation, post-procedural monitoring, pain management, early mobilization, and discharge planning.
- Long-term follow-up. Long-term follow-up includes care by the Heart Valve Team for the first 30 days after the procedure, with subsequent formal transfer of care back to the referring cardiologist; antithrombotic therapy with clopidogrel 75 mg for the first 6 months for balloon expandable valves and for 3 months with self-expanding valves, and aspirin 75-100 mg lifelong; management of other cardiac diseases; monitoring for post-TAVR complications with echocardiography (before discharge, at 30 days, and then annually) and electrocardiography; and long-term dental hygiene and antibiotic prophylaxis.
Keywords: Cardiac Surgical Procedures, Geriatrics, Angiography, Diagnostic Imaging, Anesthesia, General, Antibiotic Prophylaxis, Aortic Valve Insufficiency, Aortic Valve Stenosis, Aspirin, Early Ambulation, Echocardiography, Transesophageal, Electrocardiography, Fibrinolytic Agents, Fluoroscopy, Heart Valve Diseases, Point-of-Care Systems, Risk Assessment, Thrombosis, Tomography, Tomography, X-Ray Computed, Transcatheter Aortic Valve Replacement
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