New TAVR Guidance Aims to Ease Evaluation, Management of Patients With Aortic Stenosis

Guidelines help clinicians determine whether a patient with aortic stenosis is a candidate for TAVR, but a new consensus document from the American College of Cardiology (ACC) aims to provide detailed recommendations on what to do from the initial patient evaluation to management after the procedure.

The “expert consensus decision pathway”—published online January 4, 2017, ahead of print in the Journal of the American College of Cardiology—provides checklists that can be used by centers already performing TAVR or those planning on starting a program to create a framework for the various processes involved in managing these patients, according to a writing committee co-chaired by Catherine Otto, MD (University of Washington, Seattle), and Dharam Kumbhani, MD (University of Texas Southwestern Medical Center, Dallas).

“The intent of this document is to provide practical guidance to heart valve programs,” Otto told TCTMD.

The guidance—which only addresses TAVR for native valve aortic stenosis (and not valve-in-valve procedures)—is divided into four main sections, each with an accompanying checklist:

• Pre-TAVR patient selection and evaluation
• Imaging assessment
• Procedure (including management of complications)
• Immediate and long-term post-TAVR management

The pre-TAVR checklist could be integrated into the electronic medical record to ensure consistency in patient evaluation, Otto said. But for those referencing the procedure and post-TAVR management, she added, “every institution’s going to just need to take these checklists as a starting point, and they will need to modify them and add details relevant to their own institutional protocols and practice.”

The authors make clear that the heart team remains central to all decisions that are made at each step.

Otto pointed out that the document reflects the best evidence that is currently available and that “as there’s new information and new data, it will need to be modified and updated.” One area that remains controversial—and may change with additional data—is antithrombotic therapy after TAVR, she said, noting that the guidance focuses on the current standard of using clopidogrel and aspirin.