Appropriate Use Criteria Released for Imaging in Valvular Heart Disease

Multiple imaging modalities can be employed to evaluate and treat valvular heart disease, and clinicians have had to seek advice from separate documents on, for example, the use of CT/MRI and echocardiography to make decisions in this setting. Now, various professional societies across specialties in cardiology and imaging have teamed up to take a new approach to appropriate use criteria (AUC).

Published online last week in the Journal of the American College of Cardiology and elsewhere, the AUC focus on a single category of disease—valvular heart disease—rather than a single imaging technology. “We believe that this approach better reflects clinical decision-making in real-world scenarios and offers the diagnostic choices available to the clinician,” say writing group chair John U. Doherty, MD (Thomas Jefferson University, Philadelphia, PA), and colleagues.

Roxana Mehran, MD (Mount Sinai Medical Center, New York, NY), who also served on the writing group, told TCTMD that the emergence of valvular heart disease therapies like transcatheter aortic and mitral valve replacement and left atrial appendage closure has meant that it’s ever more important to look “for the right patient, for the right procedure, for the right treatment strategy.” Meanwhile, imaging modalities have evolved and their use has grown more specific in different areas.

As such, the developers of the AUC thought it was time to “really think about what is the appropriate, best-possible imaging modality for all of these different scenarios,” Mehran said. The latest document was created in conjunction with AUC on structural heart disease, which are forthcoming, she added.

Commenting in a press release, Doherty said: “As imaging technologies and clinical applications continue to advance, the healthcare community must understand how best to incorporate these technologies into daily clinical care and how to choose between new and established imaging technologies.”

‘Better, More Cost-effective, and More Efficient Way’

Most physicians already have a strong grasp on what imaging to use in this setting, Mehran observed, but “there’s a lot I think that we could do better with. I think that this document really does help guide physicians [on] which imaging modality would yield the best possible results for what it is they’re looking for in their minds.”

Asked if there were any particularly controversial points in the AUC, Mehran said that “in the end, it really does make a lot of intuitive sense. . . . What this document does is bring your perspective back to where it needs to be based on evidence and based on what data is there to help guide you towards a better, more cost-effective, and more efficient way with the best yield.”

Specifically, the AUC scenarios address patients across the spectrum of asymptomatic to severely symptomatic, with the use of various imaging modalities—transesophageal echocardiography transthoracic echocardiography, cardiac magnetic resonance, and others. Tables address surgical and transcatheter valve procedures as well as diagnoses including mitral valve stenosis and regurgitation, endocarditis, and aortic stenosis.

“Some of these scenarios replicate those of prior documents, but many are new, specifically, structural valve interventions, which were not in the armamentarium of clinicians when prior, single-modality documents were published. Where comparisons can be made, the ratings are remarkably consistent with prior documents,” Doherty et al state.

The document’s goal, they say, is to determine “the range of modalities that may or may not be reasonable for specific indications . . . rather than determining a single best test for each indication or a rank order.”

Sometimes more than one imaging type may be considered appropriate, may be appropriate, or rarely appropriate for a certain clinical scenario. In these cases, “physician judgment and available local expertise should be used to determine the choice of test,” the authors advise.