Sandbox: TAVI - AUC

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

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.

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	bgcolor="LightCoral" | 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	bgcolor="LightCoral" | 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	bgcolor="LightGreen" | 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	bgcolor="LemonChiffon" | 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	bgcolor="LightGreen" | 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	bgcolor="LightCoral" | 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	bgcolor="LightGreen" | 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	bgcolor="LightCoral" | 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	bgcolor="LightGreen" | 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.

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.