Deciding Which Treatment Is Appropriate for Patients with Severe Aortic Stenosis

Background and Objective

Eleven medical specialty societies developed this collaborative document providing appropriate use criteria for treating patients with severe aortic stenosis (AS). The document, the first to classify treatment options for AS, is particularly relevant in the current era of surgical and transcatheter aortic valve replacement (SAVR and TAVR). The writing group characterized 95 scenarios based on patient symptoms and clinical presentation; for each scenario, another panel rated up to six potential treatment options as “appropriate,” “maybe appropriate,” or “rarely appropriate.”

Key Points

• For patients with asymptomatic, high-gradient, severe AS, AVR may be appropriate but was rated as appropriate only if patients had an abnormal exercise stress test or other predictors of symptom onset or rapid progression, such as elevated brain natriuretic peptide. For patients with reduced ejection fraction (EF) or very high gradients (mean ≥60 mm Hg), “no intervention” was considered rarely appropriate.

• In patients with reduced EF and truly severe AS, AVR was considered appropriate; however, it was rarely appropriate in the scenario of low gradient, low EF, and minimal calcification. Balloon aortic valvuloplasty (BAV) may be appropriate as a bridge to decision in several scenarios of high or intermediate surgical risk with low flow plus low gradient and either severe low EF or lack of flow reserve.

• In several scenarios involving high- or extreme-risk patients, the panel recommended differentiation between TAVR and SAVR. For example, TAVR may be appropriate (but SAVR was only infrequently rated as such) for patients with limited life expectancy owing to multiple comorbidities or frailty. Further differentiation of treatment options was involved in other conditions; e.g., in oxygen-dependent lung disease, no intervention, BAV, and TAVR might be appropriate, whereas SAVR was considered rarely appropriate.

• For those with severe AS and coronary artery disease (CAD), percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) were also considered. SAVR plus CABG was considered appropriate, and various combinations of PCI and TAVR were considered possibly or rarely appropriate, depending on surgical risk and CAD complexity assessed by SYNTAX score.

• The most complex clinical scenarios and treatment algorithms occurred when patients had other valve or aortic pathology. SAVR and other surgery was mostly rated appropriate, but TAVR plus MitraClip was considered possibly appropriate for some scenarios of high surgical risk or of intermediate risk plus severe secondary mitral regurgitation.

• The last six scenarios addressed failing aortic-valve bioprostheses. Overall, SAVR was appropriate, and BAV was rarely appropriate, whereas TAVR was generally rated as appropriate or possibly appropriate, depending on the clinical scenario.