Sandbox: TAVI - AUC: Difference between revisions

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Line 16: Line 16:
|-  
|-  
| - LVEF ≤50%   
| - LVEF ≤50%   
- Vmax 4.0–4.9 m/sec - Negative exercise stress test 
- Vmax 4.0–4.9 m/sec  


- No predictors of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension) - High or intermediate surgical risk  
- Negative exercise stress test 
 
- No predictors of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension)  
 
- High or intermediate surgical risk  
| bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)
| bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)
|-  
|-  
| - LVEF ≤50%   
| - LVEF ≤50%   
- Vmax 4.0–4.9 m/sec - Negative exercise stress test   
- Vmax 4.0–4.9 m/sec  
 
- Negative exercise stress test   
 
- No predictors of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension) 


- No predictors of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension)  - Low surgical risk  
- Low surgical risk  
| bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)
| bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)
|-  
|-  
| - LVEF ≥50%   
| - LVEF ≥50%   
- Vmax 4.0–4.9 m/sec - High-risk profession (e.g., airline pilot) or lifestyle (e.g., competitive athlete) or anticipated prolonged time away from close medical supervision   
- Vmax 4.0–4.9 m/sec  
 
- High-risk profession (e.g., airline pilot) or lifestyle (e.g., competitive athlete) or anticipated prolonged time away from close medical supervision   


- Low surgical risk  
- Low surgical risk  
Line 34: Line 44:
|-  
|-  
| - LVEF ≥50%   
| - LVEF ≥50%   
- Vmax 4.0–4.9 m/sec - High-risk profession (e.g., airline pilot) or lifestyle (e.g., competitive athlete) or anticipated prolonged time away from close medical supervision   
- Vmax 4.0–4.9 m/sec  
 
- High-risk profession (e.g., airline pilot) or lifestyle (e.g., competitive athlete) or anticipated prolonged time away from close medical supervision   


- Low surgical risk  
- Low surgical risk  
Line 40: Line 52:
|-  
|-  
| - LVEF ≥50%   
| - LVEF ≥50%   
- Vmax 4.0–4.9 m/sec - Negative exercise stress test   
- Vmax 4.0–4.9 m/sec  
 
- Negative exercise stress test   
 
- ≥1 predictor(s) of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension) 


- ≥1 predictor(s) of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension)  - High or intermediate surgical risk  
- High or intermediate surgical risk  
| bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)  
| bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)  
|-  
|-  
| - LVEF ≥50%   
| - LVEF ≥50%   
- Vmax 4.0–4.9 m/sec - Negative exercise stress test   
- Vmax 4.0–4.9 m/sec  
 
- Negative exercise stress test   
 
- ≥1 predictor(s) of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension) 


- ≥1 predictor(s) of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension)  - Low surgical risk  
- Low surgical risk  
| bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8)
| bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8)
|-  
|-  
| - LVEF ≥50% - Vmax 4.0–4.9 m/sec   
| - LVEF ≥50%  
- Abnormal exercise stress test - High or intermediate surgical risk  
- Vmax 4.0–4.9 m/sec   
- Abnormal exercise stress test  
 
- High or intermediate surgical risk  
| bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8)
| bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8)
|-  
|-  
| - LVEF ≥50%   
| - LVEF ≥50%   
- Vmax 4.0–4.9 m/sec - Abnormal exercise stress test   
- Vmax 4.0–4.9 m/sec  
 
- Abnormal exercise stress test   


- Low surgical risk  
- Low surgical risk  
Line 62: Line 87:
|-  
|-  
| - LVEF ≥50%   
| - LVEF ≥50%   
- Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg) - High or intermediate surgical risk  
- Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg)  
 
- High or intermediate surgical risk  
| bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)
| bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)
|-  
|-  
| - LVEF ≥50%   
| - LVEF ≥50%   
- Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg) - Low surgical risk  
- Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg)  
 
- Low surgical risk  
| bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (8)
| bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (8)
|-  
|-  
| - LVEF <50%   
| - LVEF <50%   
- Very severe AS (Vmax ≥4 m/sec or mean gradient ≥40 mmHg) - High or intermediate surgical risk  
- Very severe AS (Vmax ≥4 m/sec or mean gradient ≥40 mmHg)  
 
- High or intermediate surgical risk  
| bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (8)
| bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (8)
|-  
|-  
| - LVEF <50%   
| - LVEF <50%   
- Very severe AS (Vmax ≥4 m/sec or mean gradient ≥40 mmHg) - Low surgical risk  
- Very severe AS (Vmax ≥4 m/sec or mean gradient ≥40 mmHg)  
 
- Low surgical risk  
| bgcolor="LightCoral" | R (1) || bgcolor="LightGreen" | A (9)
| bgcolor="LightCoral" | R (1) || bgcolor="LightGreen" | A (9)
|-  
|-  
Line 95: Line 128:
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
- LVEF 20% to 49% - Low flow   
- LVEF 20% to 49%  
 
- Low flow   
 
- Low gradient   


- Low gradient  - Flow reserve on low-dose dobutamine echo   
- Flow reserve on low-dose dobutamine echo   


- Truly severe AS  - High or intermediate surgical risk
- Truly severe AS   
|| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8)
 
- High or intermediate surgical risk
| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
- LVEF 20% to 49% - Low flow 
- LVEF 20% to 49%  


- Low gradient  - Flow reserve on low-dose dobutamine echo  
- Low flow  


- Truly severe AS - Low surgical risk  
- Low gradient   
|| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (9)
 
- Flow reserve on low-dose dobutamine echo 
 
- Truly severe AS  
 
- Low surgical risk  
| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (9)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
- LVEF 20% to 49% - Low flow   
- LVEF 20% to 49%  
 
- Low flow   
 
- Low gradient   


- Low gradient  - Flow reserve on low-dose dobutamine echo   
- Flow reserve on low-dose dobutamine echo   


- Pseudosevere AS  
- Pseudosevere AS  
|| bgcolor="LightGreen" | A (8) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (2)
| bgcolor="LightGreen" | A (8) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (2)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
- LVEF 20% to 49%  - Low flow   
- LVEF 20% to 49%  
 
- Low flow  
 
- Low gradient   
 
- No flow reserve on low-dose dobutamine echo  


- Low gradient  - No flow reserve on low-dose dobutamine echo
- Very calcified aortic valve on echo and/or CT, suggesting truly severe AS, or calculation of a projected valve area that remains severely reduced 


- Very calcified aortic valve on echo and/or CT, suggesting truly severe AS, or calculation of a projected valve area that remains severely reduced  - High or intermediate surgical risk  
- High or intermediate surgical risk  
|| bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7)
| bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
- LVEF 20% to 49% - Low flow 
- LVEF 20% to 49%  


- Low gradient  - No flow reserve on low-dose dobutamine echo  
- Low flow   


- Minimal calcification on aortic valve on echo and/or CT - High or intermediate surgical risk  
- Low gradient   
|| bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (2)
 
- No flow reserve on low-dose dobutamine echo 
 
- Minimal calcification on aortic valve on echo and/or CT  
 
- High or intermediate surgical risk  
| bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (2)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)   
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)   
- LVEF <20% - Vmax ≥4 m/sec or mean gradient ≥40 mmHg on resting echo   
- LVEF <20%  
 
- Vmax ≥4 m/sec or mean gradient ≥40 mmHg on resting echo   


- High or intermediate surgical risk  
- High or intermediate surgical risk  
|| bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)
| bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)   
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)   
- LVEF <20% - Mean gradient <20 mmHg on resting echo 
- LVEF <20%  


- No flow reserve on low-dose dobutamine echo  - High or intermediate surgical risk  
- Mean gradient <20 mmHg on resting echo 
|| bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3)
 
- No flow reserve on low-dose dobutamine echo   
 
- High or intermediate surgical risk  
| bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
- LVEF <20%  - Low flow  
- LVEF <20%  
 
- Low flow  
 
- Low gradient   
 
- Flow reserve on low-dose dobutamine echo  


- Low gradient  - Flow reserve on low-dose dobutamine echo 
- Truly severe AS 


- Truly severe AS  - High or intermediate surgical risk  
- High or intermediate surgical risk  
|| bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7)
| bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo   
- LVEF <20%  - Low flow   
- LVEF <20%  
 
- Low flow 
 
- Low gradient   
 
- Flow reserve on low-dose dobutamine echo 
 
- Pseudosevere severe AS 
 
- High or intermediate surgical risk
| bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (2)
|-
| colspan="4" | '''Preserved Ejection Fraction (≥50%)'''
|-
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) 
- Vmax ≥4 m/sec or mean gradient ≥40 mmHg on resting echo   
 
- Symptomatic 
 
- High or intermediate surgical risk
| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (9)
|-
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) 
- Vmax ≥4 m/sec or mean gradient ≥40 mmHg on resting echo 
 
- Symptomatic 
 
- Low surgical risk
| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (1) || bgcolor="LightGreen" | A (9)
|-
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) 
- Low flow  - Low gradient - Symptomatic 
 
- Evidence of a severely calcified valve   
 
- Clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms 
 
- High or intermediate surgical risk
| bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8)
|-
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) 
- Low flow 
 
- Low gradient 
 
- Symptomatic 
 
- Evidence of a severely calcified valve 
 
- Clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms 
 
- Low surgical risk
| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (1) || bgcolor="LightGreen" | A (9)
|-
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)  
- Low flow  
 
- Low gradient 
 
- Evidence of a severely calcified valve   
 
- Asymptomatic  
 
- High or intermediate surgical risk
| bgcolor="LemonChiffon" | M (6) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4)
|-
| - AVA ≤1.0 cm2 (and indexed AVA ≤0.6 cm2/m2) 
- Low gradient   
 
- Low flow 
 
- Evidence of a severely calcified valve   
 
- Asymptomatic 
 
- Low surgical risk
| bgcolor="LemonChiffon" | M (6) || bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (4)
|-
| - AVA ≤1.0 cm2 (and indexed AVA ≤0.6 cm2/m2) 
- Normal flow   
 
- Low gradient 
 
- Confirmation of internal consistency of the AVA, flow, and gradient measurements   
 
- Evidence of a severely calcified valve 
 
- Symptoms believed to be due to AS 
 
- High or intermediate surgical risk
| bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)
|-
| - AVA ≤1.0 cm2 (and indexed AVA ≤0.6 cm2/m2) 
- Normal flow   
 
- Low gradient 
 
- Confirmation of internal consistency of the AVA, flow, and gradient measurements   
 
- Evidence of a severely calcified valve 
 
- Symptoms believed to be due to AS 
 
- Low surgical risk
| bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (7)
|- 
| colspan="4" | '''A''' = Appropriate; '''AS''' = aortic stenosis; '''AVA''' = aortic valve area; '''AVR''' = aortic valve replacement; '''BAV''' = balloon aortic valvuloplasty; '''CT''' = computed tomography; '''LVEF''' = left ventricular ejection fraction; '''M''' = May Be Appropriate; '''R''' = Rarely Appropriate; '''SAVR''' = surgical aortic valve replacement; '''TAVR''' = transcatheter aortic valve replacement; '''Vmax''' = peak aortic valve velocity.
|}
 
===Severe AS: High- or Extreme-Risk Patients===
 
===Appropriate Use Median Score (1–9)===
 
{| class="wikitable" style="width: 80%; text-align: justify;"
! style="width:70%" | '''Indication'''
! style="width:10%" | '''No Intervention'''
! style="width:10%" | '''BAV (as Bridge to Decision)'''
! style="width:10%" | '''TAVR'''
! style="width:10%" | '''SAVR'''
|-
| '''Due to Multiple Comorbidities''' || || || ||
|-
| - Severe symptomatic AS 
- STS-PROM 8%–15%   
 
- Health status seems to be influenced more by comorbidities than by AS 
 
- Anticipated life expectancy >1 y
| bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (4)
|-
| - Severe symptomatic AS 
- STS-PROM 8%–15%   
 
- Health status seems to be influenced more by AS than by comorbidities 
 
- Anticipated life expectancy >1 y
| bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5)
|-
| - Severe symptomatic AS 
- STS-PROM 8%–15%   
 
- Health status seems to be influenced more by comorbidities than by AS 
 
- Anticipated life expectancy <1 y
| bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (1)
|-
| - Severe symptomatic AS 
- STS-PROM 8%–15%   
 
- Health status seems to be influenced more by AS than by comorbidities 
 
- Anticipated life expectancy <1 y
| bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (2)
|-
| - Severe symptomatic AS 
- STS-PROM >15%   


- Low gradient  - Flow reserve on low-dose dobutamine echo  
- Health status seems to be influenced more by comorbidities than by AS  


- Pseudosevere severe AS  - High or intermediate surgical risk
- Anticipated life expectancy >1 y
|| bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (2)
| bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightCoral" | R (2)
|-  
|-  
| '''Preserved Ejection Fraction (≥50%)''' || || ||
| - Severe symptomatic AS 
- STS-PROM >15%   
 
- Health status seems to be influenced more by AS than by comorbidities 
 
- Anticipated life expectancy >1 y
| bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (3)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) - Vmax ≥4 m/sec or mean gradient ≥40 mmHg on resting echo - Symptomatic - High or intermediate surgical risk || bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (9)
| - Severe symptomatic AS 
- STS-PROM >15%   
 
- Health status seems to be influenced more by comorbidities than by AS 
 
- Anticipated life expectancy <1 y
| bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (1)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) - Vmax ≥4 m/sec or mean gradient ≥40 mmHg on resting echo - Symptomatic - Low surgical risk || bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (1) || bgcolor="LightGreen" | A (9)
| - Severe symptomatic AS 
- STS-PROM >15%   
 
- Health status seems to be influenced more by AS than by comorbidities 
 
- Anticipated life expectancy <1 y
| bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (1)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) - Low flow - Low gradient - Symptomatic - Evidence of a severely calcified valve - Clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms - High or intermediate surgical risk || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8)
| '''With Frailty or Disability''' || || || ||
|-
| - Severe AS (Vmax 4–4.9 m/s) 
- STS-PROM 8%–15%   
 
- Frail 
 
- No chest pain or syncope   
 
- Fatigue but no shortness of breath 
 
- Normal BNP
| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (3)
|-
| - Severe AS (Vmax 4–4.9 m/s) 
- STS-PROM 8%–15%   
 
- Frail 
 
- No chest pain or syncope   
 
- Fatigue but no shortness of breath 
 
- BNP elevated
| bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (4)
|-
| - Severe AS (Vmax ≥5 m/s) 
- STS-PROM 8%–15%   
 
- Frail 
 
- No chest pain or syncope   
 
- Fatigue but no shortness of breath 
 
- Normal BNP
| bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (4)
|-
| - Severe AS (Vmax ≥5 m/s) 
- STS-PROM 8%–15%   
 
- Frail 
 
- No chest pain or syncope   
 
- Fatigue but no shortness of breath 
 
- BNP elevated
| bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (4)
|-
| - Severe AS (Vmax ≥4 m/s) 
- STS-PROM 8%-15%   
 
- Dependent in >3 activities of daily living (bathing, dressing, eating, ambulating, toileting, transferring) 
 
- Shortness of breath
| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (2)
|-
| - Severe AS (Vmax ≥4 m/s) 
- STS-PROM 8%-15%   
 
- Dependent in >3 activities of daily living (bathing, dressing, eating, ambulating, toileting, transferring) 
 
- Fatigue but no shortness of breath
| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (2)
|-
| '''Due to Anatomy''' || || || ||
|-
| - Severe symptomatic AS 
- Porcelain aorta or hostile chest 
 
- Otherwise high or intermediate surgical risk due to comorbidities
| bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (8) || bgcolor="LightCoral" | R (3)
|-
| - Severe symptomatic AS 
- Porcelain aorta or hostile chest 
 
- Otherwise low surgical risk due to comorbidities
| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (4)
|-
| '''Due to Specific Comorbidities''' || || || ||
|-
| - Severe AS
- STS-PROM 8%–15% 
- Oxygen-dependent lung disease 
 
- Shortness of breath 
 
- BNP normal
| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (3)
|-
| - Severe AS
- STS-PROM 8%–15% 
- Oxygen-dependent lung disease   
 
- Shortness of breath 
 
- BNP elevated
| bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (8) || bgcolor="LemonChiffon" | M (4)
|-
| - Severe symptomatic AS 
- STS-PROM >15%   
 
- End-stage renal disease 
 
- Longstanding dialysis, not a renal transplant candidate 
 
- Multiple comorbidities
| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightCoral" | R (2)
|-
| - Severe symptomatic AS
- STS-PROM 8%–15% 
- End-stage renal disease   
 
- Short time on dialysis 
 
- Renal transplant candidate 
 
- Nondiabetic, nonhypertensive ethology
| bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7)
|-
| - Severe symptomatic AS 
- STS-PROM 8%–15% 
 
- Cirrhosis with MELD >14
| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (2)
|-
| - Severe symptomatic AS 
- STS-PROM 8%–15% 
 
- Cirrhosis with MELD <10
| bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5)
|-
| - Severe symptomatic AS 
- STS-PROM 8%–15%   
 
- Moderate to severe dementia (minimally oriented) 
 
- Symptoms described by family but not verbalized by the patient
| bgcolor="LightGreen" | A (8) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (1)
|-
| - Severe symptomatic AS 
- STS-PROM 8%–15%   
 
- Malignancy 
 
- Life expectancy >1 year
| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (6)
|-
| - Severe symptomatic AS 
- STS-PROM 8%–15%   
 
- Malignancy 
 
- Life expectancy <1 year
| bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (1)
|-
| colspan="5" | '''A''' = Appropriate; '''AS''' = aortic stenosis; '''BAV''' = balloon aortic valvuloplasty; '''BNP''' = b-type natriuretic peptide; '''M''' = May Be Appropriate; '''MELD''' = model for end-stage liver disease; '''R''' = Rarely Appropriate; '''SAVR''' = surgical aortic valve replacement; '''STS-PROM''' = Society of Thoracic Surgeons predicted risk of mortality score; '''TAVR''' = transcatheter aortic valve replacement; Vmax = peak aortic valve velocity.
|}
 
===Symptomatic, High-Gradient, Severe AS with Associated CAD===
 
===Appropriate Use Median Score (1–9)===
 
{| class="wikitable" style="width: 80%; text-align: justify;"
! style="width:50%" | '''Indication'''
! style="width:10%" | '''TAVR'''
! style="width:10%" | '''TAVR + PCI'''
! style="width:10%" | '''SAVR'''
! style="width:10%" | '''SAVR + PCI'''
! style="width:10%" | '''SAVR + CABG'''
|-
| - 1- or 2-vessel CAD, no proximal LAD involvement 
- High or intermediate surgical risk
| bgcolor="LightGreen" | A (7) || bgcolor="LightGreen" | A (7) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)
|-
| - 1- or 2-vessel CAD, no proximal LAD involvement 
- Low surgical risk
| bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (6) || bgcolor="LemonChiffon" | M (5) || bgcolor="LightGreen" | A (7)
|-
| - 1- or 2-vessel CAD, including LAD involvement 
- High or intermediate surgical risk
| bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)
|-
| - 1- or 2-vessel CAD, including LAD involvement 
- Low surgical risk
| bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (9)
|-
| - 3-vessel disease; SYNTAX <22 
- High or intermediate surgical risk
| bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)
|-
| - 3-vessel disease; SYNTAX <22 
- Low risk
| bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (3) || bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (9)
|-
| - 3-vessel disease; SYNTAX ≥22 
- High or intermediate surgical risk
| bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4) || bgcolor="LightGreen" | A (7)
|-
| - 3-vessel disease; SYNTAX ≥22 
- Low surgical risk
| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (9)
|-
| - Left main; SYNTAX <33 
- High or intermediate surgical risk
| bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (7) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8)
|-
| - Left main; SYNTAX <33 
- Low surgical risk
| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (9)
|-
| - Left main; SYNTAX ≥33 
- High or intermediate surgical risk  
| bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (6) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (3) || bgcolor="LightGreen" | A (8)
|-
| - Left main; SYNTAX ≥33 
- Low surgical risk
| bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (2) || bgcolor="LightCoral" | R (1) || bgcolor="LightCoral" | R (2) || bgcolor="LightGreen" | A (9)
|-
| colspan="6" | '''A''' = Appropriate; '''AS''' = aortic stenosis; '''AVA''' = aortic valve area; '''CABG''' = coronary artery bypass grafting; '''CAD''' = coronary artery disease; '''LAD''' = left anterior descending; '''M''' = May Be Appropriate; '''PCI''' = percutaneous coronary intervention; '''R''' = Rarely Appropriate; '''SAVR''' = surgical aortic valve replacement; '''SYNTAX''' = synergy between PCI with TAXUS drug-eluting stent and cardiac surgery; '''TAVR''' = transcatheter aortic valve replacement; '''Vmax''' = peak aortic valve velocity.
|}
 
===Non cardiac Surgery===
 
===Appropriate Use Median Score (1–9)===
 
{| class="wikitable" style="width: 80%; text-align: justify;"
! style="width:70%" | '''Indication'''
! style="width:10%" | '''No Intervention'''
! style="width:10%" | '''BAV'''
! style="width:10%" | '''AVR (TAVR or SAVR)'''
|-
| - Symptomatic severe / critical AS 
- Elective major surgery  - Nonobstructive CAD
| bgcolor="LightCoral" | R (1) || bgcolor="LemonChiffon" | M (4)  || bgcolor="LightGreen" | A (8)
|-
| - Symptomatic / severe critical AS 
- Urgent major surgery  - Nonobstructive CAD
| bgcolor="LightCoral" | R (2) || bgcolor="LemonChiffon" | M (6)  || bgcolor="LightGreen" | A (7)
|-
| - Asymptomatic severe / critical AS 
- Elective major surgery  - Nonobstructive CAD 
 
- No signs of cardiac decompensation
| bgcolor="LemonChiffon" | M (4) || bgcolor="LightCoral" | R (3)  || bgcolor="LightGreen" | A (7)
|-
| - Asymptomatic severe / critical AS 
- Urgent major surgery  - Nonobstructive CAD 
 
- No signs of cardiac decompensation
| bgcolor="LemonChiffon" | M (5) || bgcolor="LemonChiffon" | M (4) || bgcolor="LemonChiffon" | M (5)
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) - Low flow - Low gradient - Symptomatic - Evidence of a severely calcified valve - Clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms - Low surgical risk || R (1) || bgcolor="LightCoral" | R (1) || bgcolor="LightGreen" | A (9)
| colspan="4" | '''A''' = Appropriate; '''AS''' = aortic stenosis; '''AVR''' = aortic valve replacement; '''BAV''' = balloon aortic valvuloplasty; '''CAD''' = coronary artery disease; '''M''' = May Be Appropriate; '''R''' = Rarely Appropriate; '''SAVR''' = surgical aortic valve replacement; '''TAVR''' = transcatheter aortic valve replacement.
|-  
|-  
| - AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) - Low flow - Low gradient - Evidence of a severely calcified valve - Asymptomatic - High or intermediate surgical risk || bgcolor="LemonChiffon" | M (6) || bgcolor="LightCoral" | R (3) || bgcolor="LemonChiffon" | M (4)
| colspan="4" | '''Median Score 1–3:''' Rarely Appropriate care for specific indication (treatment is not generally acceptable and is not a reasonable approach for the indication). '''Median Score 4–6:''' May Be Appropriate care for specific indication (treatment may be generally acceptable and may be a reasonable approach for the indication). '''Median Score 7–9:''' Appropriate care for specific indication (treatment is generally acceptable and is a reasonable approach for the indication).
|}
|}

Latest revision as of 17:25, 1 November 2017


Template:TAVI - AUC Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

ACC/AATS/AHA/ASE/EACTS/ HVS/SCA/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for the Treatment of Patients With Severe Aortic Stenosis

Asymptomatic, High-Gradient, Severe AS

Appropriate Use Median Score (1–9)

Indication No Intervention AVR (TAVR or SAVR)
- LVEF ≤50%

- Vmax 4.0–4.9 m/sec

- Negative exercise stress test

- No predictors of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension)

- High or intermediate surgical risk

A (7) M (5)
- LVEF ≤50%

- Vmax 4.0–4.9 m/sec

- Negative exercise stress test

- No predictors of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension)

- Low surgical risk

A (7) M (5)
- LVEF ≥50%

- Vmax 4.0–4.9 m/sec

- High-risk profession (e.g., airline pilot) or lifestyle (e.g., competitive athlete) or anticipated prolonged time away from close medical supervision

- Low surgical risk

M (4) A (7)
- LVEF ≥50%

- Vmax 4.0–4.9 m/sec

- High-risk profession (e.g., airline pilot) or lifestyle (e.g., competitive athlete) or anticipated prolonged time away from close medical supervision

- Low surgical risk

M (4) A (7)
- LVEF ≥50%

- Vmax 4.0–4.9 m/sec

- Negative exercise stress test

- ≥1 predictor(s) of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension)

- High or intermediate surgical risk

M (4) A (7)
- LVEF ≥50%

- Vmax 4.0–4.9 m/sec

- Negative exercise stress test

- ≥1 predictor(s) of symptom onset or of rapid progression (e.g., DVmax >0.3 m/s/y, severe valve calcification, elevated BNP, or excessive LV hypertrophy in the absence of hypertension)

- Low surgical risk

M (4) A (8)
- LVEF ≥50%

- Vmax 4.0–4.9 m/sec - Abnormal exercise stress test

- High or intermediate surgical risk

R (3) A (8)
- LVEF ≥50%

- Vmax 4.0–4.9 m/sec

- Abnormal exercise stress test

- Low surgical risk

R (2) A (8)
- LVEF ≥50%

- Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg)

- High or intermediate surgical risk

M (4) A (7)
- LVEF ≥50%

- Very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg)

- Low surgical risk

R (2) A (8)
- LVEF <50%

- Very severe AS (Vmax ≥4 m/sec or mean gradient ≥40 mmHg)

- High or intermediate surgical risk

R (2) A (8)
- LVEF <50%

- Very severe AS (Vmax ≥4 m/sec or mean gradient ≥40 mmHg)

- Low surgical risk

R (1) A (9)
- Undergoing another cardiac surgery or ascending aortic surgery R (1) A (9)
A = Appropriate; AS = aortic stenosis; AVR = aortic valve replacement; BNP = b-type natriuretic peptide; LV = left ventricular/left ventricle; LVEF = left ventricular ejection fraction; M = May Be Appropriate; R = Rarely Appropriate; SAVR = surgical aortic valve replacement; TAVR = transcatheter aortic valve replacement; Vmax = peak aortic valve velocity.

Flow, Gradient and Ejection Fraction

Appropriate Use Median Score (1–9)

Indication No Intervention BAV (as Bridge to Decision) AVR (TAVR or SAVR)
Reduced Ejection Fraction (<50%)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo

- LVEF 20% to 49%

- Low flow

- Low gradient

- Flow reserve on low-dose dobutamine echo

- Truly severe AS

- High or intermediate surgical risk

R (1) R (3) A (8)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo

- LVEF 20% to 49%

- Low flow

- Low gradient

- Flow reserve on low-dose dobutamine echo

- Truly severe AS

- Low surgical risk

R (1) R (2) A (9)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo

- LVEF 20% to 49%

- Low flow

- Low gradient

- Flow reserve on low-dose dobutamine echo

- Pseudosevere AS

A (8) R (2) R (2)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo

- LVEF 20% to 49%

- Low flow

- Low gradient

- No flow reserve on low-dose dobutamine echo

- Very calcified aortic valve on echo and/or CT, suggesting truly severe AS, or calculation of a projected valve area that remains severely reduced

- High or intermediate surgical risk

M (4) M (5) A (7)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo

- LVEF 20% to 49%

- Low flow

- Low gradient

- No flow reserve on low-dose dobutamine echo

- Minimal calcification on aortic valve on echo and/or CT

- High or intermediate surgical risk

A (7) R (3) R (2)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)

- LVEF <20%

- Vmax ≥4 m/sec or mean gradient ≥40 mmHg on resting echo

- High or intermediate surgical risk

R (3) M (4) A (7)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)

- LVEF <20%

- Mean gradient <20 mmHg on resting echo

- No flow reserve on low-dose dobutamine echo

- High or intermediate surgical risk

A (7) M (4) R (3)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo

- LVEF <20%

- Low flow

- Low gradient

- Flow reserve on low-dose dobutamine echo

- Truly severe AS

- High or intermediate surgical risk

R (3) M (5) A (7)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2) on resting echo

- LVEF <20%

- Low flow

- Low gradient

- Flow reserve on low-dose dobutamine echo

- Pseudosevere severe AS

- High or intermediate surgical risk

A (7) R (2) R (2)
Preserved Ejection Fraction (≥50%)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)

- Vmax ≥4 m/sec or mean gradient ≥40 mmHg on resting echo

- Symptomatic

- High or intermediate surgical risk

R (1) R (2) A (9)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)

- Vmax ≥4 m/sec or mean gradient ≥40 mmHg on resting echo

- Symptomatic

- Low surgical risk

R (1) R (1) A (9)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)

- Low flow - Low gradient - Symptomatic

- Evidence of a severely calcified valve

- Clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms

- High or intermediate surgical risk

R (2) R (3) A (8)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)

- Low flow

- Low gradient

- Symptomatic

- Evidence of a severely calcified valve

- Clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms

- Low surgical risk

R (1) R (1) A (9)
- AVA ≤1.0 cm2 (or indexed AVA ≤0.6 cm2/m2)

- Low flow

- Low gradient

- Evidence of a severely calcified valve

- Asymptomatic

- High or intermediate surgical risk

M (6) R (3) M (4)
- AVA ≤1.0 cm2 (and indexed AVA ≤0.6 cm2/m2)

- Low gradient

- Low flow

- Evidence of a severely calcified valve

- Asymptomatic

- Low surgical risk

M (6) R (2) M (4)
- AVA ≤1.0 cm2 (and indexed AVA ≤0.6 cm2/m2)

- Normal flow

- Low gradient

- Confirmation of internal consistency of the AVA, flow, and gradient measurements

- Evidence of a severely calcified valve

- Symptoms believed to be due to AS

- High or intermediate surgical risk

R (3) M (4) A (7)
- AVA ≤1.0 cm2 (and indexed AVA ≤0.6 cm2/m2)

- Normal flow

- Low gradient

- Confirmation of internal consistency of the AVA, flow, and gradient measurements

- Evidence of a severely calcified valve

- Symptoms believed to be due to AS

- Low surgical risk

R (3) R (3) A (7)
A = Appropriate; AS = aortic stenosis; AVA = aortic valve area; AVR = aortic valve replacement; BAV = balloon aortic valvuloplasty; CT = computed tomography; LVEF = left ventricular ejection fraction; M = May Be Appropriate; R = Rarely Appropriate; SAVR = surgical aortic valve replacement; TAVR = transcatheter aortic valve replacement; Vmax = peak aortic valve velocity.

Severe AS: High- or Extreme-Risk Patients

Appropriate Use Median Score (1–9)

Indication No Intervention BAV (as Bridge to Decision) TAVR SAVR
Due to Multiple Comorbidities
- Severe symptomatic AS

- STS-PROM 8%–15%

- Health status seems to be influenced more by comorbidities than by AS

- Anticipated life expectancy >1 y

M (4) M (5) A (7) M (4)
- Severe symptomatic AS

- STS-PROM 8%–15%

- Health status seems to be influenced more by AS than by comorbidities

- Anticipated life expectancy >1 y

R (2) M (4) A (8) M (5)
- Severe symptomatic AS

- STS-PROM 8%–15%

- Health status seems to be influenced more by comorbidities than by AS

- Anticipated life expectancy <1 y

A (8) M (5) R (3) R (1)
- Severe symptomatic AS

- STS-PROM 8%–15%

- Health status seems to be influenced more by AS than by comorbidities

- Anticipated life expectancy <1 y

M (6) M (5) M (4) R (2)
- Severe symptomatic AS

- STS-PROM >15%

- Health status seems to be influenced more by comorbidities than by AS

- Anticipated life expectancy >1 y

M (6) M (5) M (6) R (2)
- Severe symptomatic AS

- STS-PROM >15%

- Health status seems to be influenced more by AS than by comorbidities

- Anticipated life expectancy >1 y

M (4) M (5) A (7) R (3)
- Severe symptomatic AS

- STS-PROM >15%

- Health status seems to be influenced more by comorbidities than by AS

- Anticipated life expectancy <1 y

A (8) M (4) R (3) R (1)
- Severe symptomatic AS

- STS-PROM >15%

- Health status seems to be influenced more by AS than by comorbidities

- Anticipated life expectancy <1 y

A (7) M (5) R (3) R (1)
With Frailty or Disability
- Severe AS (Vmax 4–4.9 m/s)

- STS-PROM 8%–15%

- Frail

- No chest pain or syncope

- Fatigue but no shortness of breath

- Normal BNP

M (5) M (4) M (5) R (3)
- Severe AS (Vmax 4–4.9 m/s)

- STS-PROM 8%–15%

- Frail

- No chest pain or syncope

- Fatigue but no shortness of breath

- BNP elevated

M (4) M (4) A (7) M (4)
- Severe AS (Vmax ≥5 m/s)

- STS-PROM 8%–15%

- Frail

- No chest pain or syncope

- Fatigue but no shortness of breath

- Normal BNP

M (4) M (5) A (7) M (4)
- Severe AS (Vmax ≥5 m/s)

- STS-PROM 8%–15%

- Frail

- No chest pain or syncope

- Fatigue but no shortness of breath

- BNP elevated

R (3) M (5) A (8) M (4)
- Severe AS (Vmax ≥4 m/s)

- STS-PROM 8%-15%

- Dependent in >3 activities of daily living (bathing, dressing, eating, ambulating, toileting, transferring)

- Shortness of breath

M (5) M (5) M (5) R (2)
- Severe AS (Vmax ≥4 m/s)

- STS-PROM 8%-15%

- Dependent in >3 activities of daily living (bathing, dressing, eating, ambulating, toileting, transferring)

- Fatigue but no shortness of breath

M (5) M (5) M (5) R (2)
Due to Anatomy
- Severe symptomatic AS

- Porcelain aorta or hostile chest

- Otherwise high or intermediate surgical risk due to comorbidities

R (2) M (4) A (8) R (3)
- Severe symptomatic AS

- Porcelain aorta or hostile chest

- Otherwise low surgical risk due to comorbidities

R (1) R (3) A (8) M (4)
Due to Specific Comorbidities
- Severe AS

- STS-PROM 8%–15% - Oxygen-dependent lung disease

- Shortness of breath

- BNP normal

M (5) M (5) A (7) R (3)
- Severe AS

- STS-PROM 8%–15% - Oxygen-dependent lung disease

- Shortness of breath

- BNP elevated

R (3) M (5) A (8) M (4)
- Severe symptomatic AS

- STS-PROM >15%

- End-stage renal disease

- Longstanding dialysis, not a renal transplant candidate

- Multiple comorbidities

M (5) M (4) M (6) R (2)
- Severe symptomatic AS

- STS-PROM 8%–15% - End-stage renal disease

- Short time on dialysis

- Renal transplant candidate

- Nondiabetic, nonhypertensive ethology

R (3) R (3) A (7) A (7)
- Severe symptomatic AS

- STS-PROM 8%–15%

- Cirrhosis with MELD >14

M (5) M (5) A (7) R (2)
- Severe symptomatic AS

- STS-PROM 8%–15%

- Cirrhosis with MELD <10

R (3) M (4) A (7) M (5)
- Severe symptomatic AS

- STS-PROM 8%–15%

- Moderate to severe dementia (minimally oriented)

- Symptoms described by family but not verbalized by the patient

A (8) R (3) R (2) R (1)
- Severe symptomatic AS

- STS-PROM 8%–15%

- Malignancy

- Life expectancy >1 year

M (5) M (4) A (7) M (6)
- Severe symptomatic AS

- STS-PROM 8%–15%

- Malignancy

- Life expectancy <1 year

A (7) M (5) R (2) R (1)
A = Appropriate; AS = aortic stenosis; BAV = balloon aortic valvuloplasty; BNP = b-type natriuretic peptide; M = May Be Appropriate; MELD = model for end-stage liver disease; R = Rarely Appropriate; SAVR = surgical aortic valve replacement; STS-PROM = Society of Thoracic Surgeons predicted risk of mortality score; TAVR = transcatheter aortic valve replacement; Vmax = peak aortic valve velocity.

Symptomatic, High-Gradient, Severe AS with Associated CAD

Appropriate Use Median Score (1–9)

Indication TAVR TAVR + PCI SAVR SAVR + PCI SAVR + CABG
- 1- or 2-vessel CAD, no proximal LAD involvement

- High or intermediate surgical risk

A (7) A (7) M (4) M (4) A (7)
- 1- or 2-vessel CAD, no proximal LAD involvement

- Low surgical risk

R (3) R (3) M (6) M (5) A (7)
- 1- or 2-vessel CAD, including LAD involvement

- High or intermediate surgical risk

M (4) A (7) R (3) M (4) A (7)
- 1- or 2-vessel CAD, including LAD involvement

- Low surgical risk

R (2) R (3) R (3) R (3) A (9)
- 3-vessel disease; SYNTAX <22

- High or intermediate surgical risk

M (4) A (7) R (3) M (4) A (7)
- 3-vessel disease; SYNTAX <22

- Low risk

R (2) R (3) R (2) M (4) A (9)
- 3-vessel disease; SYNTAX ≥22

- High or intermediate surgical risk

R (3) M (6) R (3) M (4) A (7)
- 3-vessel disease; SYNTAX ≥22

- Low surgical risk

R (1) R (2) R (2) R (3) A (9)
- Left main; SYNTAX <33

- High or intermediate surgical risk

R (2) A (7) R (2) R (3) A (8)
- Left main; SYNTAX <33

- Low surgical risk

R (1) R (2) R (2) R (3) A (9)
- Left main; SYNTAX ≥33

- High or intermediate surgical risk

R (2) M (6) R (2) R (3) A (8)
- Left main; SYNTAX ≥33

- Low surgical risk

R (1) R (2) R (1) R (2) A (9)
A = Appropriate; AS = aortic stenosis; AVA = aortic valve area; CABG = coronary artery bypass grafting; CAD = coronary artery disease; LAD = left anterior descending; M = May Be Appropriate; PCI = percutaneous coronary intervention; R = Rarely Appropriate; SAVR = surgical aortic valve replacement; SYNTAX = synergy between PCI with TAXUS drug-eluting stent and cardiac surgery; TAVR = transcatheter aortic valve replacement; Vmax = peak aortic valve velocity.

Non cardiac Surgery

Appropriate Use Median Score (1–9)

Indication No Intervention BAV AVR (TAVR or SAVR)
- Symptomatic severe / critical AS

- Elective major surgery - Nonobstructive CAD

R (1) M (4) A (8)
- Symptomatic / severe critical AS

- Urgent major surgery - Nonobstructive CAD

R (2) M (6) A (7)
- Asymptomatic severe / critical AS

- Elective major surgery - Nonobstructive CAD

- No signs of cardiac decompensation

M (4) R (3) A (7)
- Asymptomatic severe / critical AS

- Urgent major surgery - Nonobstructive CAD

- No signs of cardiac decompensation

M (5) M (4) M (5)
A = Appropriate; AS = aortic stenosis; AVR = aortic valve replacement; BAV = balloon aortic valvuloplasty; CAD = coronary artery disease; M = May Be Appropriate; R = Rarely Appropriate; SAVR = surgical aortic valve replacement; TAVR = transcatheter aortic valve replacement.
Median Score 1–3: Rarely Appropriate care for specific indication (treatment is not generally acceptable and is not a reasonable approach for the indication). Median Score 4–6: May Be Appropriate care for specific indication (treatment may be generally acceptable and may be a reasonable approach for the indication). Median Score 7–9: Appropriate care for specific indication (treatment is generally acceptable and is a reasonable approach for the indication).
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