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%) | |||
| - 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 indica- tion (treatment is generally acceptable and is a reasonable approach for the indication). | |||