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
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%) |