In the Journals

ACC releases new guidance for assessing TAVR eligibility

The American College of Cardiology has released a guidance document for determining patient eligibility for transcatheter aortic valve replacement.

“We set out to develop practice tools that could readily help centers — those that either want to start doing TAVR or that are already performing it — improve their processes, patient safety and outcomes,” Catherine M. Otto, MD, FACC, professor of medicine at the University of Washington in Seattle and co-chair of the document’s writing committee, said in a press release. “The resulting checklists are designed as a starting point for managing patients who are being considered for TAVR.”

According to the document, titled “The 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults with Aortic Stenosis,” decision-making regarding TAVR should be conducted by a multidisciplinary, collaborative team of specialists, including experts with experience in valvular heart disease, structural interventional cardiologists, imaging specialists, CV surgeons, CV anesthesiologists and CV nursing professionals.

The document presents checklists for guiding clinicians during each stage of TAVR patient selection and care.

Risk determination

According to the document, patients being considered for TAVR should have severe symptomatic aortic stenosis (Stage D). Notably, an underlying risk for surgical AVR is another key component of TAVR consideration.

The writing committee noted that its discussion of the topic assumes risk stratification based on the American Heart Association/ACC 2014 guideline for the management of patients with valvular heart disease, section 2.5. This assessment is a combination of the Society of Thoracic Surgeons’ predicted risk of mortality (PROM) score, frailty, main organ system dysfunction and procedure-specific issues. The document recommends baseline clinical examinations that include physical examination, blood work, pulmonary function testing and carotid ultrasound where appropriate. Functional tests are also recommended, including tests to evaluate frailty, physical function, independence in daily activities and cognitive function.

Other considerations include comorbidities that may increase procedural risk or affect outcomes, and futility, which refers to avoiding treatment in patients who do not stand to benefit in terms of quality of life or increased survival.
The researchers added that after collecting the appropriate information and diagnostic tests, treatment decisions should be made on an individual basis, according to clinical/imaging evaluation, risk category, patient goals/expectations and futility considerations. They noted that preplanning should be done in terms of valve device choice, annular sizing, vascular access, left ventricle geometry and aortic valve morphology.

The guidance document also discusses avoiding complications and long-term management.

Optimal use

The writers recommended that the checklist items of the document be embedded into electronic medical records to facilitate complete testing and care for all patients undergoing TAVR.

“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,” Otto said in the 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.” – by Jennifer Byrne

Disclosure: Otto reports no relevant financial disclosures. Please see the full statement for a list of the relevant financial disclosures of the other authors and reviewers.

The American College of Cardiology has released a guidance document for determining patient eligibility for transcatheter aortic valve replacement.

“We set out to develop practice tools that could readily help centers — those that either want to start doing TAVR or that are already performing it — improve their processes, patient safety and outcomes,” Catherine M. Otto, MD, FACC, professor of medicine at the University of Washington in Seattle and co-chair of the document’s writing committee, said in a press release. “The resulting checklists are designed as a starting point for managing patients who are being considered for TAVR.”

According to the document, titled “The 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults with Aortic Stenosis,” decision-making regarding TAVR should be conducted by a multidisciplinary, collaborative team of specialists, including experts with experience in valvular heart disease, structural interventional cardiologists, imaging specialists, CV surgeons, CV anesthesiologists and CV nursing professionals.

The document presents checklists for guiding clinicians during each stage of TAVR patient selection and care.

Risk determination

According to the document, patients being considered for TAVR should have severe symptomatic aortic stenosis (Stage D). Notably, an underlying risk for surgical AVR is another key component of TAVR consideration.

The writing committee noted that its discussion of the topic assumes risk stratification based on the American Heart Association/ACC 2014 guideline for the management of patients with valvular heart disease, section 2.5. This assessment is a combination of the Society of Thoracic Surgeons’ predicted risk of mortality (PROM) score, frailty, main organ system dysfunction and procedure-specific issues. The document recommends baseline clinical examinations that include physical examination, blood work, pulmonary function testing and carotid ultrasound where appropriate. Functional tests are also recommended, including tests to evaluate frailty, physical function, independence in daily activities and cognitive function.

Other considerations include comorbidities that may increase procedural risk or affect outcomes, and futility, which refers to avoiding treatment in patients who do not stand to benefit in terms of quality of life or increased survival.
The researchers added that after collecting the appropriate information and diagnostic tests, treatment decisions should be made on an individual basis, according to clinical/imaging evaluation, risk category, patient goals/expectations and futility considerations. They noted that preplanning should be done in terms of valve device choice, annular sizing, vascular access, left ventricle geometry and aortic valve morphology.

The guidance document also discusses avoiding complications and long-term management.

Optimal use

The writers recommended that the checklist items of the document be embedded into electronic medical records to facilitate complete testing and care for all patients undergoing TAVR.

“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,” Otto said in the 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.” – by Jennifer Byrne

Disclosure: Otto reports no relevant financial disclosures. Please see the full statement for a list of the relevant financial disclosures of the other authors and reviewers.