ACC releases expert consensus decision pathway for TAVR patients

The American College of Cardiology (ACC) released an expert consensus decision pathway to provide a framework for physicians to manage adults with aortic stenosis who are undergoing transcatheter aortic valve replacement (TAVR).

The document was published online Jan. 4 in the Journal of the American College of Cardiology.

Catherine M. Otto, MD, and Dharam J. Kumbhani, MD, SM, were co-chairs of the nine-member writing committee. James L. Januzzi Jr, MD, was the chair of the 16-person task force on clinical expert consensus documents.

“TAVR is one of the most rapidly expanding technologies in medical care today, and as our population ages, we will see increasing numbers of people with severe aortic valve stenosis, so it is important to provide guidance on optimal use of this treatment,” Otto said in a news release. “There is also a great deal of interest among patients who usually prefer TAVR over open heart valve surgery, if this option is appropriate for their medical condition.”

Since the FDA approved the first TAVR valve in 2011, more than 50,000 patients in the U.S. have undergone TAVR, according to the authors. As of now, TAVR devices are only approved in intermediate to high surgical risk or inoperable patients with aortic stenosis. However, the authors said TAVR would likely be used in the future in low-risk surgical candidates.

In this document, the authors provided point-of-care checklists and algorithms to help with TAVR decision-making. They wrote that the checklist is based on recommendations in the 2014 ACC/American Heart Association guidelines for managing patients with valvular heart disease. They also noted the document addresses TAVR for patients with native valve aortic stenosis, but it does not address valve-in-valve procedures.

“Many aspects of management of TAVR patients are undergoing rapid change, necessitating general recommendations, for example, in the choice of agent, dose, and duration of anti-thrombotic therapy after TAVR,” the authors wrote. “Readers are urged to use these checklists as a starting point, revising them as needed to match institutional protocols and updating details as new clinical data become available.”

The document focused on four areas: preprocedure evaluation of the patient being considered for TAVR, imaging modalities and measurements, key issues in performing the TAVR procedure and recommendations for patient follow-up after TAVR.

The authors said the expert consensus decision pathways complement clinical practice guidelines and focus on issues that are not adequately addressed by existing clinical trials.

“Decision pathways are not intended to provide a single correct answer, but to encourage clinicians to ask certain questions and consider important factors as they come to their own decision on a treatment plan for their patients,” Januzzi wrote in the document. “There may be multiple pathways that can be taken for treatment decisions and the goal is to help clinicians make a more informed decision.”