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| | I C || For patients in whom TAVR or high-risk surgical AVR is being considered, a heart valve team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care. || 2014 recommendation remains current. || | | | I C || For patients in whom TAVR or high-risk surgical AVR is being considered, a heart valve team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care. || 2014 recommendation remains current. || |
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| | I B-NR || Surgical AR is recommended for symptomatic patients with severe AS (Stage D) and asymptomatic patients with severe AS (Stage C) who meet an indication for AVR when surgical risk is low or intermediate. || MODIFIED: LOE updated from A to B-NR. Prior recommendations for intervention choice did not specify patient symptoms. The patient population recommended for surgical AVR encompasses both symptomatic and asymptomatic patients who meet an indication for AVR with low-to-intermediate surgical risk. This is opposed to the patient population recommended for TAVR, in whom symptoms are required to be present. Thus, all recommendations for type of intervention now specify the symptomatic status of the patient. || | | | I B-NR || Surgical AR is recommended for symptomatic patients with severe AS (Stage D) and asymptomatic patients with severe AS (Stage C) who meet an indication for AVR when surgical risk is low or intermediate. || MODIFIED: LOE updated from A to B-NR. Prior recommendations for intervention choice did not specify patient symptoms. The patient population recommended for surgical AVR encompasses both symptomatic and asymptomatic patients who meet an indication for AVR with low-to-intermediate surgical risk. This is opposed to the patient population recommended for TAVR, in whom symptoms are required to be present. Thus, all recommendations for type of intervention now specify the symptomatic status of the patient. || |
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| ===Timing of Intervention===
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| | |
| {|class="wikitable"
| |
| |-
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| | colspan="1" style="text-align:center; background:LightGreen"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1. '''[[AVR]] is recommended with severe high-gradient [[AS]] who have symptoms by history or on exercise testing ([[Aortic stenosis stages|stage D1]])([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2. '''[[AVR]] is recommended for asymptomatic patients with severe [[AS]] ([[Aortic stenosis stages|stage C2]])and LVEF <50% ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3. '''[[AVR]] is indicated for patients with severe [[AS]] ([[Aortic stenosis stages|stage C or D]]) when undergoing other cardiac surgery ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |}
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| | |
| {|class="wikitable"
| |
| |-
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
| |
| |-
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[AVR]] is reasonable for asymptomatic patients with very severe [[AS]] ([[Aortic stenosis stages|stage C1]], aortic velocity ≥5.0 m/s) and low surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2. '''[[AVR]] is reasonable in asymptomatic patients ([[Aortic stenosis stages|stage C1]]) with severe [[AS]] and decreased exercise tolerance or an exercise fall in [[BP]] ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3. '''[[AVR]] is reasonable in symptomatic patients with low-flow/low-gradient severe [[AS]] with reduced LVEF ([[Aortic stenosis stages|stage D2]]) with a low-dose [[dobutamine]] stress study that shows an aortic velocity ≥ 4.0 m/s (or mean pressure gradient ≥ 40 mm Hg) with a valve area ≤ 1.0 cm2 at any [[dobutamine]] dose ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4. '''[[AVR]] is reasonable in symptomatic patients who have low-flow/low-gradient severe AS ([[Aortic stenosis stages|stage D3]]) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5. '''[[AVR]] is reasonable for patients with moderate [[AS]] ([[Aortic stenosis stages|stage B]]) (aortic velocity 3.0–3.9 m/s) who are undergoing other [[cardiac surgery]] ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |}
| |
| | |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
| |
| |-
| |
| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[AVR]] may be considered for asymptomatic patients with severe [[AS]] ([[Aortic stenosis stages|stage C1]]) and rapid disease progression and low surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |}
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| ===Choice of Surgical or Transcatheter Intervention===
| |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1. '''Surgical [[AVR]] is recommended in patients who meet an indication for [[AVR]] with low or intermediate surgical risk. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
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| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2. '''For patients in whom [TAVR or high-risk surgical [[AVR]] is being considered, members of a Heart Valve Team should collaborate to provide optimal patient care ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3. '''TAVR is recommended in patients who meet an indication for [[AVR]] for [[AS]] who have a prohibitive surgical risk and a predicted post-TAVR survival >12 months ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |}
| |
| | |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
| |
| |-
| |
| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''TAVR is a reasonable alternative to surgical [[AVR]] in patients who meet an indication for [[AVR]] and who have high surgical risk ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |}
| |
| | |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"|[[EHS ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
| |
| |-
| |
| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''[[Aortic stenosis valvuloplasty|Percutaneous aortic balloon dilation]] may be considered as a bridge to surgical or transcatheter AVR in severely symptomatic patients with severe [[AS]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |}
| |
| | |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
| |
| |-
| |
| | bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Transcatheter aortic valve implantation|TAVR]] is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of [[AS]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |}
| |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]
Overview
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease
Aortic Stenosis
Choice of Intervention
| COR LOE |
RECOMMENDATION |
COMMENT/RATIONALE
|
| I C |
For patients in whom TAVR or high-risk surgical AVR is being considered, a heart valve team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care. |
2014 recommendation remains current. |
|
| I B-NR |
Surgical AR is recommended for symptomatic patients with severe AS (Stage D) and asymptomatic patients with severe AS (Stage C) who meet an indication for AVR when surgical risk is low or intermediate. |
MODIFIED: LOE updated from A to B-NR. Prior recommendations for intervention choice did not specify patient symptoms. The patient population recommended for surgical AVR encompasses both symptomatic and asymptomatic patients who meet an indication for AVR with low-to-intermediate surgical risk. This is opposed to the patient population recommended for TAVR, in whom symptoms are required to be present. Thus, all recommendations for type of intervention now specify the symptomatic status of the patient. |
|