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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 e103 CLINICAL STATEMENTS AND GUIDELINES

9.	 Percutaneous aortic balloon dilation has a role in treating children, adolescents, and young adults with AS, but its role in treating older patients is very limited. The mechanism by which balloon dilation modestly reduces the severity of stenosis in older patients is fracture of calcific deposits within the valve leaflets and, to a minor degree, stretching of the annulus and separation of the calcified or fused commissures. Immediate hemodynamic results include a

Table 14.  A Simplified Framework With Examples of Factors Favoring SAVR, TAVI, or Palliation Instead of Aortic Valve Intervention

Favors SAVR Favors TAVI Favors Palliation

Age/life expectancy* Younger age/longer life expectancy Older age/fewer expected remaining years of life Limited life expectancy Valve anatomy BAV

Subaortic (LV outflow tract) calcification Rheumatic valve disease Small or large aortic annulus† Calcific AS of a trileaflet valve

Prosthetic valve preference Mechanical or surgical bioprosthetic valve preferred

Concern for patient–prosthesis mismatch (annular enlargement might be considered) Bioprosthetic valve preferred

Favorable ratio of life expectancy to valve durability TAVI provides larger valve area than same size SAVR

Concurrent cardiac conditions Aortic dilation‡

Severe primary MR Severe CAD requiring bypass grafting Septal hypertrophy requiring myectomy AF Severe calcification of the ascending aorta (“porcelain” aorta) Irreversible severe LV systolic dysfunction

Severe MR attributable to annular calcification

Noncardiac conditions Severe lung, liver, or renal disease

Mobility issues (high procedural risk with sternotomy) Symptoms likely attributable to noncardiac conditions

Severe dementia Moderate to severe involvement of ≥2 other organ systems

Frailty Not frail or few frailty measures Frailty likely to improve after TAVI Severe frailty unlikely to improve after TAVI Estimated procedural or surgical risk of SAVR or TAVI SAVR risk low

TAVI risk high TAVI risk low to medium

SAVR risk high to prohibitive Prohibitive SAVR risk (>15%) or post- TAVI life expectancy <1 y

Procedure-specific impediments Valve anatomy, annular size, or low coronary ostial height precludes TAVI

Vascular access does not allow transfemoral TAVI Previous cardiac surgery with at-risk coronary grafts

Previous chest irradiation Valve anatomy, annular size, or coronary ostial height precludes TAVI

Vascular access does not allow transfemoral TAVI

Goals of Care and patient preferences and values Less uncertainty about valve durability

Avoid repeat intervention Lower risk of permanent pacer Life prolongation Symptom relief Improved long-term exercise capacity and QOL Avoid vascular complications Accepts longer hospital stay, pain in recovery period Accepts uncertainty about valve durability and possible repeat intervention

Higher risk of permanent pacer Life prolongation Symptom relief Improved exercise capacity and QOL Prefers shorter hospital stay, less postprocedural pain Life prolongation not an important goal

Avoid futile or unnecessary diagnostic or therapeutic procedures Avoid procedural stroke risk Avoid possibility of cardiac pacer

*Expected remaining years of life can be estimated from US Actuarial Life Expectancy tables. The balance between expected patient longevity and valve durability varies continuously across the age range, with more durable valves preferred for patients with a longer life expectancy. Bioprosthetic valve durability is finite (with shorter durability for younger patients), whereas mechanical valves are very durable but require lifelong anticoagulation. Long-term (20-y) data on outcomes with surgical bioprosthetic valves are available; robust data on transcatheter bioprosthetic valves extend only to 5 y, leading to uncertainty about longer-term outcomes. The decision about valve type should be individualized on the basis of patient-specific factors that might affect expected longevity. †A large aortic annulus may not be suitable for currently available transcatheter valve sizes. With a small aortic annulus or aorta, a surgical annulus-enlarging procedure may be needed to allow placement of a larger prosthesis and avoid patient–prosthesis mismatch. ‡Dilation of the aortic sinuses or ascending aorta may require concurrent surgical replacement, particularly in younger patients with a BAV. AF indicates atrial fibrillation; AS, aortic stenosis; BAV, bicuspid aortic valve; CAD, coronary artery disease; LV, left ventricular; MR, mitral regurgitation; QOL, quality of life; SAVR, surgical aortic valve replacement; and TAVI, transcatheter aortic valve implantation.

Modified from Burke et al.16

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