American College of Cardiology Releases Consensus-Driven Decision Pathway for TAVR

The American College of Cardiology (ACC) has issued a decision pathway to for the selection, treatment, and follow-up care of patients with aortic stenosis who may be candidates for transcatheter aortic valve replacement (TAVR).
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Aortic stenosis occurs when the heart’s aortic valve narrows, thus restricting blood flow throughout the body. Aortic valve replacement serves as a common surgical treatment for aortic stenosis; however, some patients with the disease are considered poor candidates for surgery, due to age of comorbidity status.

TAVR is a minimally invasive procedure in which an aortic valve is replaced through the femoral artery in a patient’s leg or through the heart’s left ventricular apex. TAVR gained approval in 2011, with more than 50,000 procedures performed since then. TAVR is currently only indicated for inoperable patients and for patients considered at intermediate- or high-risk for surgical complications.

“TAVR is one of the most rapidly expanding technologies in medical care today, and as our population ages, we will see increasing numbers of people with severe aortic valve stenosis, so it is important to provide guidance on optimal use of this treatment,” Catherine M Otto, MD, FACC, J Ward Kennedy Endowed Chair in cardiology, professor of medicine, and director of the Heart Valve Clinic at University of Washington School of Medicine (Seattle, WA), as well as a co-chair of the ACC’s writing committee, said in a press release. “There is also a great deal of interest among patients who usually prefer TAVR over open heart valve surgery, if this option is appropriate for their medical condition.”

The ACC formed a 16-member expert task force to develop consensus guidelines, as well as a nine-member writing committee. The panel composed recommendations to standardize practices in four major areas of TAVR treatment: preprocedure considerations; the selection and timing of appropriate imaging tests and measurements; key issues and considerations associated with the TAVR procedure and complication management; and appropriate immediate and long-term follow-up care.

The expert panel crafted extensive checklists for each of the four areas of focus. They recommended that the decision-making process in the preprocedure phase include a multidisciplinary medical team comprised of cardiologists with specialized training in valvular heart desire, structural interventional cardiologists, imaging specialists, cardiovascular surgeons and anesthesiologists, and trained cardiovascular surgeons.

Following TAVR referral, patients should receive an initial assessment, at which time it would be determined whether they should continue with periodic monitoring or proceed to a functional assessment. Patients whose functional assessment suggests a life expectancy of less than 1 year or who exhibit other signs suggesting futility should be referred to palliative care; other patients should proceed to an overall risk assessment. The panel affirmed that patients with a lower surgical risk than currently approved TAVR indications allow should continue to proceed to aortic valve replacement, whereas patients who are not suited for surgical management proceed to TAVR.

The panel recommended transthoracic echocardiography (TTE) and multidetector computed tomography (MDCT) for initial imaging, with preprocedure imaging in place to determine aortic valve morphology and function. MDCT should be used for annular sizing in the preprocedure phase and for aortic root measurements. Uses of imaging in the periprocedural phase include interventional planning, confirmation of annular sizing, valve placement, paravalvular leak, and the identification of any procedural complications. Long-term imaging recommendations include the use of echocardiography to evaluate valve function and TTE to monitor changes in left ventricular functioning.

Guidelines for preprocedural planning include the selection of an appropriate valve (balloon-expandable, self-expanding, or other), the selection of an access point, the selection of an appropriate procedure location, and the anticipation and preparation of potential anesthetic complications. Treatment teams are further encouraged to identify potential complications, and take available steps to mitigate their risk.

Recommendations for immediate postprocedure management include early extubation for patients treated under general anesthesia, appropriate pain management, and structured discharge planning. Providers are encouraged to follow hospital protocols for monitoring vital scenes, mental health, postprocedure blood testing, and telemetry. Recommendations for long-term care include the transfer of primary management from the heart valve team to the patient’s cardiologist following 30 days; the initiation of appropriate antithrombotic therapy; and the appropriate treatment of cardiac and noncardiac comorbidities. The panel recommends echocardiography at 30 days postprocedure to asses post-TAVR complications, followed by annual echocardiography. Because endocarditis is a long-term risk for TAVR patients, proper dental hygiene is stressed.

“Many aspects of management of TAVR patients are undergoing rapid change, necessitating general recommendations, for example, in the choice of agent, dose, and duration of antithrombotic therapy after TAVR,” the authors wrote. “Readers are urged to use these checklists as a starting point, revising them as needed to match institutional protocols, and updating details as new clinical data become available.” – Cameron Kelsall