Written By: Jennifer Hakkarainen, PA-C Cardiology

Transcatheter aortic valve replacement is the go-to option for high-risk patients who require aortic valve replacement but aren’t candidates for surgery. According to Martin B. Leon, MD, FACC, this procedure can almost triple life expectancy among this population.[1]

According to David R. Holmes, Jr., MD, MACC, past ACC president, since its inception in 2002, “TAVR has transformed the care of more than 300,000 patients with severe aortic stenosis (AS) worldwide and allowing them to receive mechanical treatment for their mechanical problem.”[2]

But what about the symptomatic intermediate-risk patient population with moderate to severe aortic stenosis? These patients are often interested in less-invasive options. They have friends and family members who have experienced valve replacement, and both the referring internist and patient have questions about their options.

The first step is evaluating them for the procedure. When evaluating patients, consider if the patient meets any of the following AVR replacement indications:

  • Severe high-gradient AS with symptoms on history or exercise testing
  • Asymptomatic severe AS with EF < 50%
  • Severe AS undergoing other cardiac surgery
  • Asymptomatic very severe AS and low surgical risk
  • Asymptomatic AS with decreased exercise tolerance or fall in systemic BP with exercise
  • Asymptomatic AS, rapid progression, low surgical risk
  • Moderate AS undergoing other cardiac surgery[3]

Even though patients may meet criteria on a checklist, to a patient who requires AVR and is expected to undergo an open heart surgery, the possibility of limited life expectancy remains, with additional risk-related contraindications and high-risk comorbidities.[4]

The good news is that although initially first reserved for patients at high surgical risk or inoperable, TAVR is currently an option for patients with symptomatic intermediate risk. This may even be expanded to patients who are considered low risk and wish for a more noninvasive procedure.

As of November 15, 2018, the Society of Thoracic Surgeons released an updated short-term risk calculator to reflect the latest adult cardiac surgery risk models. For those at moderate or intermediate surgical risk—classified as having a Society of Thoracic Surgeons (STS) score ≥4-8 percent in the update—TAVR is a reasonable alternative to SAVR.

The ACC’s 2017 Expert Consensus Decision Pathway for TAVR appears to offer clear guidance for clinical centers performing TAVR and those considering starting a TAVR program. The document was designed to provide a framework for evaluation of TAVR candidates. This process includes outlining key steps in patient selection, evaluation, imaging assessment, issues in performing the TAVR procedure, and recommendations for post-TAVR management. The pathway also includes algorithms with critical steps to facilitate process and pre-procedural work-up, procedural steps, and weighing out potential complications.

When it comes to educating patients who are interested in this less-invasive option, I explain that deciding if they are a candidate for TAVR involves a complex work-up and careful decision-making with a heart team. Currently, our practice has a solid relationship with a tertiary care facility with a heart team/TAVR expertise. It is my experience that the patient with symptomatic degenerative calcific AS must at the very least be able to undergo an extensive outpatient evaluation prior to determining candidacy and risk stratification. However, the ultimate decision/care of potential TAVR candidates, especially when determining risk for TAVR procedure, remains in the care of the heart team discussion.

The Wellness Network offers patient education programming to help patients understand valve conditions and procedures like TAVR. Learn more about our comprehensive Cardiology Library developed in partnership with the American Heart Association.


References

[1] https://www.acc.org/latest-in-cardiology/articles/2017/07/19/15/42/fifteen-years-of-tavr-where-are-we-now

[2] https://www.acc.org/latest-in-cardiology/articles/2017/07/19/15/42/fifteen-years-of-tavr-where-are-we-now

[3] Nishimura et al. Circulation. 2014

[4] 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease – JACC (2014)