AHA: AS Flashcards
dx testing: initial dx
pre-imaging optimization for suspected low-flow, low-gradient AS with normal EF
BP control
(1)
“In patients with suspected low-flow, lowgradient severe AS with normal LVEF (Stage D3), optimization of blood pressure control is recommended before measurement of AS severity by TTE, TEE, cardiac catheterization, or CMR.”
dx testing: initial dx
preferred imaging/testing for suspected low-flow, low-gradient AS with reduced EF
low-dose dobutamine stress ECHO OR invasive hemodynamic testing (i.e. LHC?)
(2a)
“In patients with suspected low-flow, lowgradient severe AS with reduced LVEF (Stage D2), low-dose dobutamine stress testing with echocardiographic or invasive hemodynamic measurements is reasonable to further define severity and assess contractile reserve.”
dx testing: initial dx
additional TTE calculation/measurement for suspected low-flow, low-gradient severe AS (with normal or reduced EF)
(not the most preferred/1st-line)
voutflow tract : vAo
(2a)
ratio of outflow tract to aortic velocities
“In patients with suspected low-flow, lowgradient severe AS with normal or reduced LVEF (Stages D2 and D3), calculation of the ratio of the outflow tract to aortic velocity is reasonable to further define severity.”
dx testing: initial dx
additional imaging for suspected low-flow, low-gradient severe AS (with normal or reduced EF)
(not the most preferred/1st-line)
cardiac CT for AV calcium score
(2a)
aortic valve calcium score by CT
♀>1400 / ♂>2000
“In patients with suspected low-flow, lowgradient severe AS with normal or reduced LVEF (Stages D2 and D3), measurement of aortic valve calcium score by CT imaging is reasonable to further define severity.”
dx testing: initial dx
additional testing for asx severe AS
exercise testing
(2a)
￬ tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise
“In asymptomatic patients with severe AS (Stage C1), exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms.”
dx testing: exercise testing
exercise testing in sx severe AS
NO
(3: harm)
“In symptomatic patients with severe AS (Stage D1, aortic velocity ≥4.0 m/s or mean pressure gradient ≥40 mmHg), exercise testing should not be performed because of the risk of severe hemodynamic compromise.”
med tx
med tx for asx AS
HTN GDMT
(1)
AND statin if calcific AS (1) AND RAS blocker if s/p TAVI (2b)
“In patients at risk of developing AS (Stage A) and in patients with asymptomatic AS (Stages B and C), hypertension should be treated according to standard GDMT, started at a low dose, and gradually titrated upward as needed, with appropriate clinical monitoring.”
med tx
med tx for calcific AS
sx or asx, i.e. all calcific AS
statin
for 1° & 2° ppx of atherosclerosis
(1)
AND HTN GDMT in asx AS (1) AND RAS blocker if s/p TAVI (2b)
“In all patients with calcific AS, statin therapy is indicated for primary and secondary prevention of atherosclerosis on the basis of standard risk scores.”
med tx
med tx for AS s/p TAVI
RAS blocker (ACE-I or ARB)
to reduce all-cause mortality
(2b)
AND HTN GDMT in asx AS (1) AND statin if calcific AS (1)
“In patients who have undergone TAVI, renin–angiotensin system blocker therapy (ACE inhibitor or ARB) may be considered to reduce the long-term risk of all-cause mortality.”
3 classic sxs of AS
- angina
- syncope
- dyspnea/CHF
in order of increasing mortality
3 classic symptoms of AS in order of increasing mortality
- angina
- syncope
- dyspnea/CHF
mean OS for AS after onset of angina
5y
ASD = angina/syncope/dyspnea = 5/3/2y
mean OS for AS after onset of syncope
3y
ASD = angina/syncope/dyspnea = 5/3/2y
mean OS for AS after onset of dyspnea/CHF
2y
ASD = angina/syncope/dyspnea = 5/3/2y
indication(s) for intervention in sx severe AS
YES
severe + sx = indicated
(1)
incl low-flow, low-gradient (1)
“1. In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.” (1)
“4. In symptomatic patients with low-flow, low gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.” (1)
“5. In symptomatic patients with low-flow, low gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.” (1)
indication(s) for intervention in sx high-gradient (usual) severe AS
YES
severe + sx = indicated
(1)
“1. In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.” (1)
indication(s) for intervention in sx low-flow, low-gradient severe AS
YES
severe + sx = indicated
incl low-flow, low-gradient with:
- reduced EF (1)
- normal EF but AS is the most likely cause of sxs (1)
“4. In symptomatic patients with low-flow, low gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.” (1)
“5. In symptomatic patients with low-flow, low gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.” (1)
indication(s) for intervention in asx severe AS
- EF<50% (1)
- concomitant <3 surg (1)
- progressive ￬ EF on 3 studies to <60% (2b)
OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)
indication(s) for intervention in asx severe AS
(7)
- EF<50% (1)
- concomitant <3 surg (1)
- progressive ￬ EF on 3 studies to <60% (2b)
OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)
class 2 indication(s) for intervention in asx severe AS
- progressive ￬ EF on 3 studies to <60% (2b)
OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)
class 2 indication(s) for intervention in asx severe AS
(5)
- progressive ￬ EF on 3 studies to <60% (2b)
OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)
class 2b indication(s) for intervention in asx severe AS
- progressive ￬ EF on 3 studies to <60% (2b)
class 2b indication(s) for intervention in asx severe AS
(1)
- progressive ￬ EF on 3 studies to <60% (2b)
class 2a indication(s) for intervention in asx severe AS
low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)
class 2a indication(s) for intervention in asx severe AS
(4)
low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- high-risk progression (i.e. vmax ￪ ≥0.3m/s/y) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- BNP > 3x nl (2a)
class 1 indication(s) for intervention in asx severe AS
- EF<50% (1)
- concomitant <3 surg (1)
class 1 indication(s) for intervention in asx severe AS
(2)
- EF<50% (1)
- concomitant <3 surg (1)
indication(s) for intervention in moderate AS
- concomitant <3 surg (2b)
regardless of sx status
“In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.”
indication(s) for intervention in moderate AS
(1)
- concomitant <3 surg (2b)
regardless of sx status
“In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.”
indication(s) for intervention in asx moderate AS
- concomitant <3 surg (2b)
(regardless of sx status)
“In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.”
indication(s) for intervention in sx moderate AS
- concomitant <3 surg (2b)
(regardless of sx status)
In reality, I think we should offer SAVR for these pts.
“In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.”
bp v mech
class 1 recommendation(s) for aortic valve choice
- shared decision-making (1)
- bp if warfarin contraindicated (1)
“In patients with an indication for AVR, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.”
“For patients of any age requiring AVR for whom VKA anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic AVR is recommended.”
bp v mech
class 1 recommendation(s) for aortic valve choice
(2)
- shared decision-making (1)
- bp if warfarin contraindicated (1)
“In patients with an indication for AVR, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.”
“For patients of any age requiring AVR for whom VKA anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic AVR is recommended.”
bp v mech
age-based guideline recommendation(s) for aortic valve choice
- <50yo = mech (2a)
- OR Ross in <50yo who prefer bp & have approp anatomy (2b)
- 50-65yo = SDM/individualized (2a)
- > 65yo = bp (2a)
assuming no contraindication to warfarin
“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”
bp v mech
guideline recommendation for aortic valve choice in <50yo
- <50yo = mech (2a)
- OR Ross in <50yo who prefer bp & have approp anatomy (2b)
- 50-65yo = SDM/individualized (2a)
- > 65yo = bp (2a)
assuming no contraindication to warfarin
“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”
bp v mech
guideline recommendation for aortic valve choice in 50-65yo
- <50yo = mech (2a)
- OR Ross in <50yo who prefer bp & have approp anatomy (2b)
- 50-65yo = SDM/individualized (2a)
- > 65yo = bp (2a)
assuming no contraindication to warfarin
“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”
bp v mech
guideline recommendation for aortic valve choice in >65yo
- <50yo = mech (2a)
- OR Ross in <50yo who prefer bp & have approp anatomy (2b)
- 50-65yo = SDM/individualized (2a)
- >65yo = bp (2a)
assuming no contraindication to warfarin
“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”
bp v mech
class 2b recommendation(s) for aortic valve choice
- Ross procedure for <50yo who prefer bp & have approp anatomy (2b)
at a CVC
“In patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy, replacement of the aortic valve by a pulmonic autograft (the Ross procedure) may be considered at a Comprehensive Valve Center.”
bp v mech
class 2b recommendation(s) for aortic valve choice
(1)
- Ross procedure for <50yo who prefer bp & have approp anatomy (2b)
at a CVC
“In patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy, replacement of the aortic valve by a pulmonic autograft (the Ross procedure) may be considered at a Comprehensive Valve Center.”
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
recommendation(s) for AVI choice (TAVI v SAVR)
- severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe AS >80yo or life expectancy <10y: TAVI (1)
- asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)
- asx severe AS with (+)exercise test, critical, rapid/high-risk progression, elevated BNP (i.e. who meet asx 2a recommendations): SAVR (1)
- AVR indicated & bp preferred but anatomy unsuitable for transfemoral TAVI: SAVR (1)
- sx severe with high/prohibitive surgical risk: TAVI (1) – if predicted post-TAVI survival is >12mo with acceptable quality of life
- sx severe AS with <12mo predicted survival after AVR OR for whome minimal improvement in quality of life is expected: SDM for palliative care (1)
- critically ill severe: perc balloon valvuloplasty as bridge to AVR (2b)
- BAV with non-calcified valve & ≤mild AR: balloon valvuloplasty reasonable (2b)
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
recommendation(s) for AVI choice (TAVI v SAVR)
(8)
- severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe AS >80yo or life expectancy <10y: TAVI (1)
- asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)
- asx severe AS with (+)exercise test, critical, rapid/high-risk progression, elevated BNP (i.e. who meet asx 2a recommendations): SAVR (1)
- AVR indicated & bp preferred but anatomy unsuitable for transfemoral TAVI: SAVR (1)
- sx severe with high/prohibitive surgical risk: TAVI (1) – if predicted post-TAVI survival is >12mo with acceptable quality of life
- sx severe AS with <12mo predicted survival after AVR OR for whome minimal improvement in quality of life is expected: SDM for palliative care (1)
- critically ill severe: perc balloon valvuloplasty as bridge to AVR (2b)
- BAV with non-calcified valve & ≤mild AR: balloon valvuloplasty reasonable (2b)
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
age-based guideline recommendation(s) for AVI choice (TAVI v SAVR)
- severe AS <65yo OR life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe AS 65-80yo: SDM (1) either TAVI or SAVR
- sx severe AS >80yo OR life expectancy <10y: TAVI (1)
[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
guideline recommendation(s) for AVI choice (TAVI v SAVR) in <65yo
- severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe AS >80yo or life expectancy <10y: TAVI (1)
[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
age-based guideline recommendation(s) for AVI choice (TAVI v SAVR) in <65yo
assuming intervention indicated
SAVR
(1)
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
age-based guideline recommendation(s) for AVI choice (TAVI v SAVR) in 65-80yo
assuming intervention indicated
SDM for either TAVI or SAVR
(1)
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
age-based guideline recommendation(s) for AVI choice (TAVI v SAVR) in >80yo
assuming intervention indicated
TAVI
(1)
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
guideline recommendation(s) for AVI choice (TAVI v SAVR) in 65-80yo
- severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe AS >80yo or life expectancy <10y: TAVI (1)
[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
guideline recommendation(s) for AVI choice (TAVI v SAVR) in >80
- severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe AS >80yo or life expectancy <10y: TAVI (1)
[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
guideline recommendation(s) for AVI choice (TAVI v SAVR) in any age with life expectancy <10y
- severe AS <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe AS 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe AS >80yo or life expectancy <10y: TAVI (1)
[asx severe AS ≤80yo with EF<50%: same as above for sx pts (1)]
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
class 2b recommendation(s) for aortic valve intervention in critically ill severe AS
- critically ill severe: perc balloon valvuloplasty as bridge to AVR (2b)
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
class 2b recommendation(s) for aortic valve intervention in non-calcified BAV AS
- BAV with non-calcified valve & ≤mild AR: balloon valvuloplasty reasonable (2b)
AHA ACHD guideline
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
class 2b recommendation(s) for aortic valve intervention in non-calcified BAV AS
(1)
- BAV with non-calcified valve & ≤mild AR: balloon valvuloplasty reasonable (2b)
AHA ACHD guideline
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
class 2b recommendation(s) for aortic valve intervention in critically ill severe AS
(1)
- critically ill severe: perc balloon valvuloplasty as bridge to AVR (2b)
indication(s) for AVR in mixed/combined AS & AR
- +sx + peak transvalvular jet v≥4.0m/s OR mean grad≥40mmHg: AVR (1)
- asx + peak transvalvular jet v≥4.0m/s AND LVEF<50%: SAVR (1)
bp v mech
aortic valve choice if warfarin contraindicated
bp
(1)
“In patients with an indication for AVR, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.”
“For patients of any age requiring AVR for whom VKA anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic AVR is recommended.”
bp v mech
aortic valve choice in <50yo
assuming no contraindication to warfarin
mech
(2a)
OR Ross in <50yo who prefer bp & have approp anatomy (2b)
“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”
bp v mech
aortic valve choice in 50-65yo
assuming no contraindication to warfarin
SDM/individualized
(2a)
for either bp or mech
“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”
bp v mech
aortic valve choice in >65yo
assuming no contraindication to warfarin
bp
(2a)
“For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.”
“For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.”
“In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.”
bp v mech
aortic valve choice in <50yo who prefer bp & have approp anatomy
at a CVC
Ross
(2b)
“In patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy, replacement of the aortic valve by a pulmonic autograft (the Ross procedure) may be considered at a Comprehensive Valve Center.”
SAVR v TAVI
AVI choice in: severe AS <65yo or life expectancy >20y with any indication for AVR
in pts for whom bp is approp
SAVR
(1)
SAVR v TAVI
AVI choice in: sx severe AS 65-80yo
in pts for whom bp is approp
SDM/individualized
(1)
SDM for either TAVI or SAVR
SAVR v TAVI
AVI choice in: sx severe AS >80yo or life expectancy <10y
in pts for whom bp is approp
TAVI
(1)
SAVR v TAVI
AVI choice in: asx severe AS ≤80yo with EF<50%
in pts for whom bp is approp
same as above for sx pts (1):
- severe <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe >80yo or life expectancy <10y: TAVI (1)
SAVR v TAVI
AVI choice in: asx severe AS with (+)exercise test, critical, rapid/high-risk progression, elevated BNP (i.e. who meet asx 2a AVR recommendations)
in pts for whom bp is approp
SAVR
(1)
SAVR v TAVI
AVI choice in: AVR indicated & bp preferred but anatomy unsuitable for transfemoral TAVI
in pts for whom bp is approp
SAVR
(1)
SAVR v TAVI
AVI choice in: sx severe AS with high/prohibitive surgical risk
if predicted post-TAVI survival is >12mo with acceptable quality of life
in pts for whom bp is approp
TAVI
(1)
AVI choice in: sx severe AS with <12mo predicted survival after AVR OR for whom minimal improvement in quality of life is expected
in pts for whom bp is approp
SDM for palliative care
(1)
AVI choice in: critically ill severe AS
in pts for whom bp is approp
perc balloon valvuloplasty as bridge to AVR
(2b)
SAVR v TAVI
AVI choice in: severe AS <65yo or life expectancy >20y with any indication for AVR
in pts for whom bp is approp
SAVR
(1)
SAVR v TAVI
AVI choice in: sx severe AS 65-80yo
in pts for whom bp is approp
SDM/individualized
(1)
SDM for either TAVI or SAVR
SAVR v TAVI
AVI choice in: sx severe AS >80yo or life expectancy <10y
in pts for whom bp is approp
TAVI
(1)
SAVR v TAVI
AVI choice in: sx severe AS >80yo
in pts for whom bp is approp
TAVI
(1)
SAVR v TAVI
AVI choice in: sx severe AS life expectancy <10y
in pts for whom bp is approp
TAVI
(1)
SAVR v TAVI
AVI choice in: asx severe AS ≤80yo with EF<50%
in pts for whom bp is approp
same as above for sx pts (1):
- severe <65yo or life expectancy >20y with any indication for AVR: SAVR (1)
- sx severe 65-80yo: SDM for either TAVI or SAVR (1)
- sx severe >80yo or life expectancy <10y: TAVI (1)
SAVR v TAVI
AVI choice in: asx mixed/combined AS & AR with peak transvalvular jet v≥4.0m/s AND LVEF<50%
SAVR
(1)
vmax in mild AS
2-3
m/s
vmax in mod AS
3-4
m/s
vmax in sev AS
≥4
m/s
vmax in crit AS
≥5
m/s
AVA in mild AS
≥1.5
cm2
AVA in mod AS
<1.5
(1.0-1.5)
cm2
AVA in sev AS
<1.0
cm2
AVA in crit AS
<0.6
cm2
mean gradient in mild AS
<20
mmHg
mean gradient in mod AS
20-40
mmHg
mean gradient in sev AS
≥40
mmHg
mean gradient in crit AS
≥60
mmHg
aortic valve
vmax = 2-3 m/s
mild AS
aortic valve
vmax = 3-4 m/s
mod AS
aortic valve
vmax ≥4 m/s
sev AS
aortic valve
vmax ≥5 m/s
crit AS
AVA ≥1.5 cm2
<2.5
mild AS
AVA = 1.0-1.5 cm2
mod AS
AVA = <1.0 cm2
sev AS
AVA = <0.6 cm2
crit AS
aortic valve
mean gradient <20 mmHg
mild AS
aortic valve
mean gradient = 20-40 mmHg
mod AS
aortic valve
mean gradient ≥40 mmHg
sev AS
aortic valve
mean gradient ≥60 mmHg
crit AS
Is degenerative or rheumatic AS more common?
degenerative
pattern of dz/pathology underlying degenerative AS
leaflet sclerosis (not fusion)
pattern of dz/pathology underlying rheumatic AS
commissural fusion
(a/w △ or “fish-mouth”-shaped orifice)
What constitutes a positive exercise test (for AS)?
- ￬exercise tolerance
- ￬SBP≥10mmHg from baseline -> peak exercise
YES
severe + sx = indicated
(1)
incl low-flow, low-gradient (1)
“1. In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.” (1)
“4. In symptomatic patients with low-flow, low gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.” (1)
“5. In symptomatic patients with low-flow, low gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.” (1)
indication(s) for intervention in sx severe AS
mgmt of severe + sx AS = indicated
(1)
“1. In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.” (1)
indication(s) for intervention in sx high-gradient (usual) severe AS
YES
severe + sx = indicated
incl low-flow, low-gradient with:
- reduced EF (1)
- normal EF but AS is the most likely cause of sxs (1)
“4. In symptomatic patients with low-flow, low gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.” (1)
“5. In symptomatic patients with low-flow, low gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.” (1)
indication(s) for intervention in sx low-flow, low-gradient severe AS
- EF<50% (1)
- concomitant <3 surg (1)
- progressive ￬ EF on 3 studies to <60% (2b)
OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
- BNP > 3x nl (2a)
indication(s) for intervention in asx severe AS
- EF<50% (1)
- concomitant <3 surg (1)
- progressive ￬ EF on 3 studies to <60% (2b)
OR if low-risk AND:
- critical AS (i.e. AVA/<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
- BNP > 3x nl (2a)
indication(s) for intervention in asx severe AS
(7)
- progressive ￬ EF on 3 studies to <60% (2b)
OR if low-risk AND:
- critical AS (i.e. AVA<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
- BNP > 3x nl (2a)
class 2 indication(s) for intervention in asx severe AS
- progressive ￬ EF on 3 studies to <60% (2b)
OR if low-risk AND:
- critical AS (i.e. AVA<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
- BNP > 3x nl (2a)
class 2 indication(s) for intervention in asx severe AS
(5)
- progressive ￬ EF on 3 studies to <60% (2b)
class 2b indication(s) for intervention in asx severe AS
- progressive ￬ EF on 3 studies to <60% (2b)
class 2b indication(s) for intervention in asx severe AS
(1)
low-risk AND:
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- critical AS (i.e. AVA<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- BNP > 3x nl (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
class 2a indication(s) for intervention in asx severe AS
low-risk AND:
- (+)exercise test (i.e. ￬exercise tolerance OR ￬SBP≥10mmHg from baseline -> peak exercise) (2a)
- critical AS (i.e. AVA<0.6cm2, MG≥60mmHg, vmax≥5) (2a)
- BNP > 3x nl (2a)
- vmax incr ≥0.3m/s/y (i.e. high-risk progression) (2a)
class 2a indication(s) for intervention in asx severe AS
(4)
- EF<50% (1)
- concomitant <3 surg (1)
class 1 indication(s) for intervention in asx severe AS
- EF<50% (1)
- concomitant <3 surg (1)
class 1 indication(s) for intervention in asx severe AS
(2)
in pts for whom bp is approp (i.e. candidates for either TAVI or SAVR)
recommendation(s) for AVI choice (TAVI v SAVR) for sx severe AS in BAV
TAVI can be considered @ CVC
(2b)
“2. In patients with BAV and symptomatic, severe AS, TAVI may be considered as an alternative to SAVR after consideration of patient-specific procedural risks, values, trade-offs, and preferences, and when the surgery is performed at a Comprehensive Valve Center.”
cardiac CT aortic valve calcium score indicative of low-flow, low-gradient AS (regardless of EF)
♀>1400 / ♂>2000
low-risk TAVI trials
Evolut Low-Risk:
<3% STS risk & μ=74yo
- TAVI non-inferior for 1° endpoint = 2y composite of death or disabling stroke
- superior for 2° endpoints = 30d disabling stroke,bleeding cx,AKI,afib
- (but ￪ mod+ AR,PPM 17% v 6%)
- ￬ AV gradient @ 1y (8.6 v 11.2 mmHg)
PARTNER 3:
<4% STS risk & μ=73yo
TAVI non-inferior AND superior for:
- 1° endpoint = 1y composite of death,stroke, rehosp
- 2° endpoints = 30d stroke,death,LOS,”poor tx outcome”
- (no ∆ in major vasc cxs, PPM, mod+ PVR)
- ￪ PVL: mod+ @ 30d = 0.8% v 0%; mild @ 1y = 30% v 2%
Evolut Low-Risk
<3% STS risk & μ=74yo
- TAVI non-inferior for 1° endpoint = 2y composite of death or disabling stroke
- superior for 2° endpoints = 30d disabling stroke,bleeding cx,AKI,afib
- (but ￪ mod+ AR,PPM 17% v 6%)
- ￬ AV gradient @ 1y (8.6 v 11.2 mmHg)
PARTNER 3
<4% STS risk & μ=73yo
TAVI non-inferior AND superior for:
- 1° endpoint = 1y composite of death,stroke, rehosp
- 2° endpoints = 30d stroke,death,LOS,”poor tx outcome”
- (no ∆ in 30d major vasc cxs, PPM, mod+ PVR)
- ￪ PVL: mod+ @ 30d = 0.8% v 0%; mild @ 1y = 30% v 2%
TAVI v SAVR in low-risk
- non-inferior for composite outcomes in both trials (PARTNER 3 & Evolut Low-Risk)
- ￬ 30d stroke/disabling stroke
- ￪ / ∅∆ PPM, mod+ AR
differences/pros&cons between balloon-expandable v self-expanding TAVI valves
balloon-expandable = SAPIEN3
- bovine
- intra-annular
- annulus size 16-28mm (valves 20-29mm)
- 14Fr sheath (except 16Fr for 29mm)
- NOT re-capturable
- lower profile (better for coronary height/access)
- ￪annular rupture (slightly) with heavily/circumferentially calcified valves
- slightly easier to implant
self-expanding = Evolut PRO
- porcine - supra-annular (so can fit a larger fxnal size in a smaller annulus or valve-in-valve)
- annulus size 18-30mm (valves 23-34mm)
- 18Fr sheath
- re-capturable
- higher profile (worse for coronary height/access)
- ￪PPM rate
- slightly better flow dynamics (preferred for small annulus OR valve-in-valve with borderline size for pt-prosth mismatch)
(per Kim & interwebs)
anatomic criteria for TAVI candidacy
- access vessels (CFAs) ≥6mm
- coronary height ≥10mm (with lg/non-effaced sinuses)
- sinus diameter ≥30mm
± annulus size 18-29mm ?
TAVI procedure steps
- bilat CFA access (6Fr R, 10Fr L), + R CFV access
- transvenous pacing wire to RV (& test it)
- heparin (ACT≥250)
- 5Fr marker pigtail up the R CFA to aortic root (basal portion of NCC)
- aortogram (achieve linear alignment of the three cusps i.e. coplanar image projection)
- get to root with J-wire ￫ 6Fr exchange catheter ￫ cross native valve with straight wire ￫ J-wire & angled pigtail stay sin ventricle
- upsize the L CFA & insert the TAVI sheath
- cross the native valve with the TAVI delivery system (may use LAO view to get into the arch) & then position with coplanar view to target implant depth of 3mm
- rapid pacing + deploy the valve (can stop at 2/3 deployed to check, can still recapture)
- stop pacing
- aortogram + TTE to check valve
- Edwards SAPIEN IFU: “Perform a supra-aortic angiogram with fluoroscopic view perpendicular to the aortic valve.”
- Houston Methodist step-by-step guide: “A series of aortograms, often with rapid right ventricular pacing to allow adequate visualization using dilute contrast, is performed at an implant angle determined from the CTA to verify linear alignment of the three cusps (coplanar image projection).”
- _Edwards Commander TAVR demo: _
- “If we want to achieve that 80/20 result which is 80% of this valve sits in the aorta & 20% in the ventricle – because all the shortening comes from the ventricle end – we want to sit this 3mm marker somewhere on the bottom of this pigtail, which is buried down here in the annulus here.”
- “For Edwards, they want us to teach 80 20. Yeah, most places that I go to, I’ll be honest, shoot for 90/10.”
- “Pace at 180, okay, looking for 1:1, our SBP≤50 & pulse pressure<10.”
size of micropuncture kit sheath
5Fr
minimum ACT for TAVI
250
aortogram/fluoro view needed to correctly position TAVI
linear alignment of the three cusps i.e. coplanar image projection
- Edwards SAPIEN IFU: “Perform a supra-aortic angiogram with fluoroscopic view perpendicular to the aortic valve.”
- Houston Methodist step-by-step guide: “A series of aortograms, often with rapid right ventricular pacing to allow adequate visualization using dilute contrast, is performed at an implant angle determined from the CTA to verify linear alignment of the three cusps (coplanar image projection).”
aortogram/fluoro view needed to cross the arch
LAO (“opens up the arch”)
- Edwards SAPIEN IFU: “Perform a supra-aortic angiogram with fluoroscopic view perpendicular to the aortic valve.”
- Houston Methodist step-by-step guide: “A series of aortograms, often with rapid right ventricular pacing to allow adequate visualization using dilute contrast, is performed at an implant angle determined from the CTA to verify linear alignment of the three cusps (coplanar image projection).”
goal rapid pacing for deployment
HR=180
1:1 capture
SBP≤50
PP<10
Where & what structures are at risk around the aortic annulus?
- bundle of His @ membranous septum @ R-non commissure triangle
- ant leaflet MV @ NCC>LCC (AMC)
Where is the R trigone with respect to the aortic valve?
NCC nadir
What is another name for the R trigone?
posteromedial
(under NCC)
characteristics of the R trigone
- R trigone (under NCC) + membranous septum (R-non interleaflet triangle) = central fibrous body between AV/MV/TV
- R trigone + L trigone + in between = aortomitral curtain (AMC)
- aka posteromedial trigone
- larger, firmer (v L trigone)
characteristics of the L trigone
- R trigone + L trigone + in between = aortomitral curtain (AMC)
- aka anterolateral trigone
- smaller, less firm (v R trigone) “L = lesser”
