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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e99 CLINICAL STATEMENTS AND GUIDELINES

risk of bleeding complications related to VKA therapy and more often require interruption of VKA therapy for noncardiac surgical and interventional procedures. It is reasonable to use a bioprosthetic valve in patients >65 years of age to avoid the risks of anticoagulation because the durability of the valve exceeds the expected years of life. 6.	 Replacement of the aortic valve with a pulmonary autograft (the Ross procedure) is a complex operation involving replacement of the aortic valve by the patient’s own pulmonic valve, along with placement of a pulmonic valve homograft. The Ross procedure allows the patient to avoid a prosthetic heart valve and the risks of anticoagulation and it provides excellent valve hemodynamics. However, both the pulmonic homograft in the pulmonic position and the pulmonary autograft (the neoaortic valve) are at risk of valve degeneration. The failure of the Ross procedure is most often attributable to regurgitation of the neoaortic valve in the second decade after the operation. In addition, at least half of pulmonic homograft valves require reintervention within 10 to 20 years. Calcification of the homograft and adhesions between the homograft and neoaorta may increase the difficulty of reoperation. The Ross procedure typically is reserved for younger patients with appropriate anatomy and tissue characteristics for whom anticoagulation is either contraindicated or undesirable, and it is performed only at Comprehensive Valve Centers by surgeons experienced in this procedure.11–13,32

3.2.4.2 Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate

Recommendations for Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate Referenced studies that support the recommendations are summarized in Online Data Supplement 11 to 13. COR LOE Recommendations

1 A 1.  For symptomatic and asymptomatic patients with severe AS and any indication for AVR who are <65 years of age or have a life expectancy >20 years, SAVR is recommended.1–3

1 A 2.  For symptomatic patients with severe AS who are 65 to 80 years of age and have no anatomic contraindication to transfemoral TAVI, either SAVR or transfemoral TAVI is recommended after shared decision-making about the balance between expected patient longevity and valve durability.1,4–8

1 A 3.  For symptomatic patients with severe AS who are >80 years of age or for younger patients with a life expectancy <10 years and no anatomic contraindication to transfemoral TAVI, transfemoral TAVI is recommended in preference to SAVR.1,4–10 1 B-NR 4.  In asymptomatic patients with severe AS and an LVEF <50% who are ≤80 years of age and have no anatomic contraindication to transfemoral TAVI, the decision between TAVI and SAVR should follow the same recommendations as for symptomatic patients in Recommendations 1, 2, and 3 above.1,2,4–10

1 B-NR 5.  For asymptomatic patients with severe AS and an abnormal exercise test, very severe AS, rapid progression, or an elevated BNP (COR 2a indications for AVR), SAVR is recommended in preference to TAVI.1–3,11

1 A 6.  For patients with an indication for AVR for whom a bioprosthetic valve is preferred but valve or vascular anatomy or other factors are not suitable for transfemoral TAVI, SAVR is recommended. 1–3,11

1 A 7.  For symptomatic patients of any age with severe AS and a high or prohibitive surgical risk, TAVI is recommended if predicted post- TAVI survival is >12 months with an acceptable quality of life.12,13,14,15

1 C-EO 8.  For symptomatic patients with severe AS for whom predicted post-TAVI or post-SAVR survival is <12 months or for whom minimal improvement in quality of life is expected, palliative care is recommended after shared decision-making, including discussion of patient preferences and values.

2b C-EO 9.  In critically ill patients with severe AS, percutaneous aortic balloon dilation may be considered as a bridge to SAVR or TAVI.

Synopsis

In patients considering a bioprosthetic AVR, the next step is the choice between SAVR and TAVI. In patients with a high or prohibitive risk for SAVR (see Section 2.5), decision-making focuses on TAVI versus palliative care. When surgical risk is not high or prohibitive, procedure-specific impediments are assessed (Figure 3). When both SAVR and TAVI are options, a prime consideration is the limited data about TAVI durability. SAVR has been used for more than 50 years, with ample durability data available for specific valve types across different age groups. Currently, robust durability data for TAVI extend to only about 5 years. SAVR valve deterioration typically occurs after >10 years, so longer-term TAVI durability data are needed. A key factor in decision-making is the ratio of patient life expectancy to known valve durability, with patient age often used as a surrogate for life expectancy. For a woman in the United States, the average additional expected years of life are 25 at age 60 years, 17 at age 70 years, and 10 at age 80 years. For a man, expected additional years of life are 22 at age 60 years, 14 at age 70 years, and 8 at age 80 years. The age breakpoints shown in these recommendations reflect these

Recommendations for Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate (Continued) COR LOE Recommendations

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