ACC Releases Decision Pathway for TAVR in Aortic Stenosis

The American College of Cardiology (ACC) has published an expert consensus document that offers a decision pathway for transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS).¹

At present, TAVR is approved for use in patients who are inoperable or have intermediate to high surgical risk. However, the authors of the consensus document note that it will likely be used in progressively lower-risk patients. The decision pathway, which includes point-of-care checklists and algorithms, is designed to provide guidance about TAVR from the point at which a patient with severe symptomatic AS is determined to be a candidate for AVR.

The document first outlines several preliminary assumptions. Patients being considered for the procedure should be adults with calcific valvular AS. They should be assessed for underlying risk for surgical AVR (SAVR) based on 2014 American Heart Association/ACC guidelines and integrating the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score and other measures.² In addition, a heart valve team must be closely involved in decision-making and application of the procedure.

The decision pathway is divided into 4 main sections.

Preprocedure Evaluation

Points covered include shared decision-making, which should be managed by a multidisciplinary team of various cardiovascular subspecialists, and areas to be included in the initial assessment, functional assessment, and risk assessment. “The final treatment decision should be individualized based on clinical and imaging evaluation, risk category, patient’s goals and expectations, and futility considerations,” the authors wrote.

TAVR Imaging and Assessment

Options are offered for imaging techniques, including transthoracic echocardiography and multidetector computed tomography, to be used in the initial assessment and evaluations conducted before, during, and after the procedure, and as critical measures to be captured on imaging. 

Key Issues Regarding Performance of TAVR

Preprocedural planning and procedural details, including “valve choice, vascular access, procedure location, anesthetic considerations, and anticipated management of potential complications,” as well as anticoagulation, and post-deployment valve assessment, are described in this section.  

Post-TAVR Management

This section details patient management in the immediate post-procedure period, including pain management and discharge planning. Additionally, long-term follow-up care is outlined, including antithrombotic therapy, aspirin, and management of comorbid cardiac diseases.

As new valves and implantation methods are developed for TAVR, different patient populations may become candidates for the procedure. The ACC writing committee concluded that while advances or changes in delivery platforms, valves, and anticoagulation may require updates to the decision pathway in the future, the general principles will remain relevant to managing these patients.

References

1. 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 [Published online January 4, 2017]. J Am Coll Cardiol. doi:10.1016/j.jacc.2016.12.006
2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185. doi:10.1016/j.jacc.2014.02.536