Society of thoracic surgeons predicted risk of mortality v.2.73
Additive EuroSCORE
Logistic EuroSCORE
EuroSCORE II
Ambler
Northern New England
New York State
Providence Health System
Veterans Affairs Risk Score
Age, Creatinine, Ejection Fraction (ACEF) Score
Australian AVR Score
German Aortic Valve Score
1.
EuroSCORE: The EuroSCORE risk predictive models include the additive and logistic EuroSCORE as well as the EuroScore II.
(a)
The additive EuroSCORE model: It was developed in 1995 and was derived from a population of 15,000 patients and from eight different countries in Europe. Twelve variables were considered in the additive EuroSCORE that were deemed predictive of early mortality.
(b)
The logistic EuroSCORE model: This was derived from the additive model and includes 18 variables. However, being based on a relatively small sample, many years ago, and in Europe, it tends to overestimate the actual surgical risk. As such, it has not been used in the any of the TAVR trials or in common clinical use in the US to predict surgical mortality [11, 12]
(c)
The EuroSCORE II model: This updated score was derived from more than 22,000 patients operated on between May and July 2010 in 43 countries worldwide. It includes all cardiac procedures and now has 18 covariates predictive of surgical aortic valve mortality. Its incremental benefit remains in question, especially as pertains to surgical AVR. Chalmers et al. [16] applied the model to a 5,500-patient cohort and concluded that EuroSCORE II is globally better calibrated than the EuroSCORE and found better overall discrimination, with a c-index of 0.79 (old model 0.77) and its best performance in mitral (0.87) and coronary (0.79) surgery; Euro SCORE II was weakest in isolated AVR (c-index 0.69), only marginally better than the old model (0.67) [16].
2.
The STS Predicted Risk of Mortality (PROM): The model was developed in a later era (2002–2006) in the United States with use of data from over 67,000 patients undergoing only isolated AVR. Twenty-four covariates for mortality have been identified. At least two series have found the STS PROM to be a better predictor of early mortality than the Logistic EuroSCORE, especially in the higher-risk patients undergoing AVR [17, 18]. The STS PROM has now been updated from version 2.73 to version 2.81. As with all risk algorithms, calibration drift occurs as the original data set becomes dated, and the algorithm will need to be updated once sufficient numbers of patients are available for the new version that has in addition captured the new possible predictors. The STS online risk calculator is capable of calculating major morbidity in addition to mortality after surgical AVR [19]. The weighting of the various risk factors is recalibrated with each new version of the STS Adult Cardiac Database according to the most recent data uploaded by the 1,005 cardiac surgery programs in the United States that participate in the database. STS version 2.81 includes 9 outcome points; risk of mortality, morbidity or mortality, long length of stay, short length of stay, permanent stroke, prolonged ventilation, DSW infection, renal failure, and reoperation.
A composite score from the STS was released in 2012 from observation studies of 3 years (June 2007–July 2010) and 5 years (June 2005–July 2010). This score was based solely on outcomes, including risk-standardized mortality and any-or-none risk-standardized morbidity (occurrence of sternal infection, reoperation, stroke, renal failure, or prolonged ventilation) [20].
Rankin et al. [21] have also published a risk prediction for multiple valve operations.
3.
Less commonly used models include:
A.
The Ambler Score was developed from a national database from the Society of Cardiothoracic Surgeons of Great Britain and Ireland on 32,839 patients who underwent heart valve surgery between April 1995 and March 2003 [22].
B.
The Northern New England risk model was derived from eight Northern New England Medical Centers in the period January 1991 through December 2001. In this model, 8,943 patients undergoing heart valve surgery were analyzed, and 11 variables in the aortic model were found to be predictive of adverse outcomes [23]. They included older age, lower body surface area, prior cardiac operation, elevated serum creatinine level, prior stroke, New York Heart Association (NYHA) functional class IV, heart failure, atrial fibrillation, acuity, year of surgery, and concomitant CABG.
C.
The Age, Creatinine, Ejection Fraction score, previously mentioned, analyzed 29,659 consecutive patients who underwent elective cardiac operations in 14 Italian institutions from 2004 to 2009 [24, 25]. Using only three variables, age serum creatinine and ejection fraction, Ranucci et al. [24, 25] found that for all deciles of risk distribution, the Logistic EuroSCORE significantly overestimated mortality risk and that the Age, Creatinine, Ejection Fraction score slightly overestimated the mortality risk in very-low-risk patients and significantly underestimated the mortality risk in very-high-risk patients, correctly estimating the risk in 7 of 10 deciles. The accuracy of the Age, Creatinine, Ejection Fraction score was acceptable (AUROC 0.702) and at least comparable to the Logistic EuroSCORE calculation.
D.
The Australian AVR score is based on 3,544 AVR procedures performed between 2001 and 2008. It contains the following predictors: age, NYHA functional class, left main disease, infective endocarditis, cerebrovascular disease, renal dysfunction, previous cardiac surgery, and estimated ejection fraction. The final model (AVR-Score) obtained an average AUROC of 0.78 for early mortality [26].
4.
Models for TAVR:
With the emergence of percutaneous approaches to AVR, there has been an interest in developing predictive risk models for the management of patients who are candidates for TAVR. The most commonly used model has been the STS PROM which was not developed nor originally intended for this procedure and may not necessarily be the most accurate method for this patient population [27]. Among the factors leading to inaccuracy include:
A.
TAVR patients are at the extremes of risk, where the current risk models fail because there are too few patients at the higher extremes of risk to be able to have robust discrimination of risk.
B.
The variables that may play significant roles in risk, including porcelain aorta, previous radiation therapy, liver disease, and frailty were included in the risk model.
C.
Some of the morbidity data included in the model do not pertain to the TAVR procedure (risk of sternal infection with the trans-femoral approach)
In order to help address some of the inadequacies of the current risk prediction models in adults undergoing aortic valve procedures, the German Aortic Valve Registry (GARY) has developed the German Aortic Valve Score [28]. It is based on 11,794 patients undergoing surgical AVR or TAVR in Germany in 2008. Using multiple logistic regression, Kötting et al. [28] identified 15 risk factors influencing in-hospital mortality. Among the most important factors determined to predict risk were age, body mass index, renal disease, urgent status, and left ventricular function. The risk model had a high degree of discrimination, with an AUROC of 0.808.
The model does, however, have many limitations including:
A.
It was developed on the basis of patients treated in 2008 and may already be not applicable to technologies currently involved in TAVR.
B.
Patients undergoing TAVR constituted only 5.1 % (573/11,147) of the study population, limiting the specific application to transcatheter valve risk prediction. Also, TAVR was performed in only 25/81 participating institutions, again limiting the “generalizability” of the score.
C.
The model was developed for inter-hospital comparisons only and therefore can predict only overall outcomes in German hospitals. Comparisons can be made of overall program outcomes between various centers, but it cannot be used to discriminate among different procedures, approaches, or devices.
D.
It also cannot as yet determine whether an individual patient should undergo surgical AVR or TAVR or whether a specific device or approach is preferable. It is also likely that different factors constitute different risk profiles for different procedures. For example, frailty may be weighted more when considering surgical AVR compared to TAVR. The risks may not be the same for the different approaches for TAVR, because severe lung disease may be a significant factor impacting outcomes with the transapical approach but not the transfemoral approach.
E.
The model was created from a derivation sample due to the small sample size of TAVR procedures in the study, and no validation sample was examined, so the model needs to be validated externally in other populations.
F.
This model is based on in-hospital mortality, which is lower than the 30-day definition of mortality used by the STS algorithm.
A true TAVR-specific risk model needs to be developed, and at least two efforts are under way.
1.
The European registries of the SAPIEN Valve (Edwards Lifesciences, Irvine, California): This identified that patients with the transapical approach (n = 575) suffered more comorbidities than transfemoral patients (n = 463) with a significantly higher logistic EuroSCORE (29 % versus 25.8 %; P = 0.007). On Multivariable analysis identified logistic EuroSCORE, renal disease, liver disease, and smoking as variables with the highest hazard ratios for 1-year mortality whereas carotid artery stenosis, hyperlipidemia, and hypertension were associated with lower mortality [29].
2.
The U.S. Placement of AoRTic TraNscathetER Valve (PARTNER) Trial, and data obtained in Continued Access patients are being collated and analyzed to develop a TAVR-specific algorithm, and the STS/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) Registry in the United States now has sufficient patients enrolled for a risk algorithm to be developed. Validation of a TAVR-specific risk algorithm between these two populations is planned. Data from the TVT registry of 7,710 patients who underwent TAVR were published and revealed that the observed incidence of in-hospital mortality was 5.5 %. The major complications included stroke (2.0 %), dialysis-dependent renal failure (1.9 %), and major vascular injury (6.4 %). Median hospital stay was 6 days. Among patients with available follow-up at 30 days (n = 3133), the incidence of mortality was 7.6 %, an major complications included a stroke in 2.8 %, new dialysis in 2.5 %, and reintervention in 0.5 % [30].
The most recent valve guidelines present a novel approach for evaluation of surgical and interventional risk for AVR [2]. This model (Table 11.2) includes several factors in addition to the STS PROM risk prediction model including:
Table 11.2
Combined evaluation of surgical and interventional risk for aortic valve replacement
Low risk (must meet all criteria in this column) | Intermediate risk (any 1 criterion in this column) | High risk (Any 1 criterion in this column) | Prohibitive risk (any 1 criterion in this column) | |
|---|---|---|---|---|
STS PROM | <4 % AND | 4–8 % OR | >8 % OR | Predicted risk with surgery of death or major morbidity (all-cause) >50 % at 1 year OR |
Frailty | None AND | 1 Index (mild) OR | ≥2 Indices (moderate to severe) OR | |
Major organ system compromise not to be improved postoperatively | None AND | 1 Organ system OR | No more than 2 organ systems OR | ≥3 Organ systems OR |
Procedure-specific impediment | None | Possible procedure-specific impediment | Possible procedure-specific impediment | Severe procedure-specific impediment |
1.
STS PROM: low risk (<4 %), intermediate risk (4–8 %), high risk (>8 %), and prohibitive (predicted risk of death or major morbidity >50 % at 1 year)
2.
Frailty: Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) and independence in ambulation or gait speed (no walking aid or assist required or 5-m walk in <6 s). Other scoring systems can be applied to calculate no, mild-, or moderate-to-severe frailty as dominant hand grip strength and serum albumin
3.
Major organ system compromise not to be improved postoperatively: This includes; Cardiac—severe LV systolic or diastolic dysfunction or RV dysfunction, fixed pulmonary hypertension; CKD stage 3 or worse; pulmonary dysfunction with FEV1 <50 % or DLCO2 <50 % of predicted; CNS dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, CVA with persistent physical limitation); GI dysfunction—Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0; cancer—active malignancy; and liver—any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy
4.
Procedure specific impediment: tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, or radiation damage
More recently, several factors have been evaluated as risk predictors in patients undergoing TAVR including:
1.
Diabetes: In an analysis of the FRANCE 2 registry, the investigators noted an interaction between the presence of diabetes, delivery approach and clinical outcome: In those who underwent femoral access TAVR, the rate of death or stroke at 1 year was similar in diabetic and nondiabetic patients (19.9 % and 20.6 %, respectively; p = 0.67), but in those who underwent nonfemoral TAVR, the rate was lower in diabetic versus nondiabetic patients (19 % vs. 30.3 %, respectively; p = 0.001) [31].
2.
Chronic kidney disease: In a study published by Allende et al., a history of atrial fibrillation (HR, 2.29; p = 0.001) and dialysis therapy (HR, 1.86; p = 0.009) on multivariate analysis, were predictors of mortality in advanced CKD patients. Patients with advanced CKD on dialysis and with a history of AF had a mortality rate of 71 % at 1 year and 100 % at 2 years, compared with 20.1 % and 28.4 %, respectively, in patients who had advanced CKD but neither of these two risk factors (p < 0.001) [32].
3.
Gender Difference: In an analysis of the PARTNER trial to determine the effect of sex on TAVR and SAVR outcomes, Procedural mortality trended lower with TAVR versus SAVR for female patients (6.8 % vs. 13.1 %; p = 0.07), although procedural stroke rates were higher (5.4 % vs. 0.7 %; p = 0.02) because of higher stroke incidence in the transfemoral arm. The difference in mortality favoring TAVR was significant at 6 months (12.2 % vs. 25.8 %; p < 0.01) and 2 years (28.2 % vs. 38.3 %; hazard ratio [HR]: 0.67; p = 0.049) [33].
4.
Pulmonary hypertension: In analysis of the FRANCE two registry, The investigators concluded that pulmonary hypertension (defined as systolic pulmonary hypertension ≥40 mmHg) in patients with severe aortic stenosis undergoing TAVR was associated with increased 1-year mortality (28 % for systolic pulmonary hypertension ≥40 mmHg vs. 22 % for systolic pulmonary hypertension <40 mmHg; p = 0.032) [34].
5.
Mitral Regurgitation: In a multicenter registry analysis of patients undergoing TAVR with the CoreValve revalving system, patients with severe or moderate MR had significantly higher mortality rates at 1 month and 1 year after TAVR compared to those with mild or no MR. At these time points, the mortality rates between those with moderate or severe MR were comparable [35].
6.
Chronic Obstructive Pulmonary Disease (COPD): In a study of 319 patients with undergoing TAVR, survival rates at 1 year were 70.6 % in COPD patients and 84.5 % in patients without COPD (p = 0.008). COPD was an independent predictor of cumulative mortality after TAVR (hazard ratio: 1.84; 95 % confidence interval: 1.08–3.13; p = 0.026). COPD patients exhibited less (p = 0.036) improvement in NYHA functional class. Among COPD patients, a shorter 6 min walk test (6MWT) distance predicted cumulative mortality (p = 0.013), whereas poorer baseline spirometry results (FEV1 [forced expiratory volume in the first second of expiration]) determined a higher rate of periprocedural pulmonary complications (p = 0.040). TAVR was futile in 40 COPD patients (42.5 %) and a baseline 6MWT distance <170 m best determined the lack of benefit after TAVR (p = 0.002) [36].
7.
Tricuspid Regurgitation (TR): In a study of 518 patients undergoing TAVR, patients were divided into either those with moderate/severe TR (79 patients) versus none/mild TR. Significant TR was associated with more comorbidities. However, was not an independent predictor of 2-year mortality. Pre-specified subgroups showed an interaction between TR and left ventricular systolic function (Pinteraction = 0.047). Interestingly, moderate/severe TR was significantly related to mortality only in patients with left ventricular ejection fraction (LVEF) >40 % (adjusted OR: 2.01, CI: 1.05–3.84, P = 0.036). In patients with LVEF ≤40 %, TR had no significant impact on all-cause mortality (adjusted OR: 1.04, CI: 0.34–3.16, P = 0.946). No significant interactions were identified regarding patients with perioperative moderate/severe mitral regurgitation (Pinteraction = 0.829) and patients with baseline systolic pulmonary artery pressure ≥60 mmHg (Pinteraction = 0.669) [37].
8.
STS >15: The survival benefit of TAVR seems to diminish in patients with high STS score. In the PARTNER trial 2 year mortality data, there was no survival benefit for TAVR in patients with an STS score >15 in comparison to standard therapy. At ACC 2014, the TVT 1-year registry data were presented and revealed a 40 % mortality in patients with an STS score >15, compared to just over 26 % in the entire cohort [38].
9.
TVT registry: Acting as a “real world” experience, at the ACC 2014, the 1-year data were presented for 5980 patients and revealed a mortality rate of 26 % and a stroke rate of 3.6 %. Male gender, COPD, impaired renal function, non trans-femoral access site, and STS score >15 were independent predictors of death. Female gender appeared the only independent predictor of stroke [38].
10.
Frailty: Mortality may be as high as 32.7% in frail patients compared to 15.9% in non frail patients.
11.
Liver disease: For patients with model for end stage liver disease (MELD) < 20 and Child Turcotte Pugh (CTP) class < C, outcomes are acceptable However, higher grades of liver disease are unknown.
As mentioned above, risk prediction models for SAVR have been developed to identify and guide operative risk for patients with severe AS. Despite its development as a surgical model, the STS PROM has also been utilized to risk stratify patients undergoing TAVR. Current risk models dedicated to patients undergoing TAVR are underway.
The Heart Valve Team, Heart Valve Center of Excellence
Management of patients with valvular heart disease has traditionally involved a variety of cardiology-related personnel. These may include a cardiologist who evaluates the patients clinically, another who interprets the non-invasive imaging diagnostic modality, an invasive cardiologist who performs the pre-AVR cardiac catheterization or obtains further invasive hemodynamic data, a cardiac anesthesiologist who monitors the patient intra-operatively, and a cardiac surgeon who evaluates the patient’s surgical candidacy. In addition, the echosonographer, and cardiac, ICU and OR nurses remain an integral part of the management team.
With the advent of percutaneous approaches for the management of valvular heart disease, patients who were previously deemed inoperative or at a high surgical risk have been considered as candidates for TAVR. The need for simultaneous, detailed and thorough evaluation of these patients has lead to the development of the Heart Valve Team to address the management of these patients with complex severe valvular heart disease.
In the most recent guidelines, the presence of a heart valve team for optimal patient selection for available procedures through a comprehensive understanding and analysis of the risk-benefit ratio of different treatment strategies and detailed counseling with the patient and family has been given a class I status.
The optimal care of the patients with complex valve disease is best performed in centers that can provide all options for diagnosis and management including the complex valve surgeries, transcatheter options, and advanced diagnostic modalities. This has lead to the development of Heart Valve Centers of Excellence .
These Centers of Excellence:
1.
Are composed of experienced healthcare providers with expertise from multiple disciplines.
2.
Offer all available options for diagnosis and management, including complex valve repair, aortic surgery, and transcatheter therapies
3.
Participate in regional or national outcome registries (as the post marketing registries and the TVT)
4.
Demonstrate adherence to national guidelines
5.
Participate in continued evaluation and quality improvement processes to enhance patient outcomes
6.
Publically report mortality and success rates. Decisions about intervention at the center should be dependent on the center’s publically available mortality rates and operative outcomes.
Novel Guidelines and Aortic Valve Replacement
The European society of cardiology (ESC) and the European association of cardiothoracic surgery (EACTS) published in 2012 [39] and the American heart association (AHA) and American college of cardiology guidelines were published in 2014 [2] and have both agreed on the definition of severe aortic valve stenosis (valve area ≤1 cm2, mean gradient ≥40 mmHg, aortic velocity >4 m/s, and indexed valve area ≤0.6 cm2). However, very severe aortic stenosis is defined as an aortic velocity of ≥5 m/s in the ACC/AHA guidelines and as ≥5.5 m/s in the ESC/EACTS guidelines.
The novelty in the 2014 ACC/AHA guidelines was the presence of stages for AS akin to that of heart failure. At risk (stage A), progressive AS (stage B), asymptomatic severe AS (stage C), and symptomatic severe AS (stage D) are the four stages of AS identified in the guidelines.
The indications for SAVR remain largely unchanged as demonstrated below for both the ACC/AHA (Tables 11.3 and 11.4) and ESC/EACTS (Table 11.5). However, given the results of the recent TAVR trials, TAVR has been introduced as an option in patients with severe AS and with prohibitive, or high surgical risk after discussion with a heart team and with a life expectancy >1 year TAVR (Tables 11.4 and 11.6). Another new indication introduced is the presence of very severe AS (velocity >5 m/s, >5.5 m/s) in the absence of symptoms with a low surgical risk.
Table 11.3
ACC/AHA timing of intervention
ACC/AHA recommendations: timing of intervention | COR | LOE |
|---|---|---|
AVR is recommended for symptomatic patients with severe high-gradient AS who have symptoms by history or on exercise testing (stage D1) | I | B |
AVR is recommended for asymptomatic patients with severe AS (stage C2) and LVEF ≤50 % | I | B |
AVR is indicated for patients with severe AS (stage C or D) when undergoing other cardiac surgery | I | B |
AVR is reasonable for asymptomatic patients with very severe AS (stage C1, aortic velocity ≥5.0 m/s) and low surgical risk | IIa | B |
AVR is reasonable in asymptomatic patients (stage C1) with severe AS and decreased exercise tolerance or an exercise fall in BP | IIa | B |
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a low-dose dobutamine stress study that shows an aortic velocity ≥4.0 m/s (or mean pressure gradient ≥40 mmHg) with a valve area ≤1.0 cm 2 at any dobutamine dose | IIa | B |
AVR is reasonable in symptomatic patients who have low-flow/low-gradient severe AS (stage D3) who are normotensive and have an LVEF ≥50 % if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms | IIa | C |
AVR is reasonable for patients with moderate AS (stage B) (aortic velocity 3.0–3.9 m/s) who are undergoing other cardiac surgery | IIa | C |
AVR may be considered for asymptomatic patients with severe AS (stage C1) and rapid disease progression and low surgical risk | IIb | C |
Table 11.4
ACC/AHA choice of AVR
ACC/AHA recommendations: choice of SAVR or TAVR | COR | LOE |
|---|---|---|
Surgical AVR is recommended in patients who meet an indication for AVR with low or intermediate surgical risk | I | A |
For patients in whom TAVR or high-risk surgical AVR is being considered, members of a Heart Valve Team should collaborate to provide optimal patient care | I | C |
TAVR is recommended in patients who meet an indication for AVR for AS who have a prohibitive surgical risk and a predicted post-TAVR survival ≥12 months | I | B |
TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk | IIa | B |
Percutaneous aortic balloon dilation may be considered as a bridge to surgical or transcatheter AVR in severely symptomatic patients with severe AS | IIb | C |
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS | III: No Benefit | B |
Table 11.5
ESC/EACTS indications for SAVR
ESC/EACTS recommendations: indications for SAVR | COR | LOE |
|---|---|---|
AVR is recommended for patients with severe AS and any symptoms related to AS | I | B |
AVR is recommended for asymptomatic patients with severe AS and systolic LV dysfunction LVEF ≤50 % not due to another cause | I | B |
AVR is indicated for patients with severe AS when undergoing CABG, surgery of the ascending aorta, or another valve | I | B |
AVR is reasonable in asymptomatic patients (with severe AS and abnormal exercise test showing symptoms on exercise clearly related to AS | I | C |
AVR should be considered in high risk patients with severe symptomatic AS who are suitable for TAVR, but in whom surgery is favored by a “heart team” based on individual risk profile and anatomic suitability | IIa | C |
AVR is reasonable for asymptomatic patients with very severe AS (aortic velocity ≥5.5 m/s) and low surgical risk | IIa | C |
AVR is reasonable in asymptomatic patients (stage C1) with severe AS and an exercise fall in BP below baseline | IIa | C |
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (with evidence of flow reserve) | IIa | C |
AVR is reasonable in symptomatic patients who have low-flow/low-gradient severe AS who are normotensive and have an LVEF ≥50 % after careful confirmation of severe AS | IIa | C |
AVR is reasonable for patients with moderate AS (aortic velocity 3.0–3.9 m/s) who are undergoing CABG, surgery of the ascending aorta, or another valve | IIa | C |
AVR may be considered for asymptomatic patients with severe AS and rapid disease progression >0.3 m/s/year and low surgical risk | IIa | C |
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (without evidence of flow reserve) | IIb | C |
AVR may be considered for asymptomatic patients with severe AS and low surgical risk if one or more is present: | IIb | C |
1. Markedly elevated natriuretic peptide levels confirmed by repeated measurements and without other explanations | ||
2. Increase of mean gradient by 20 mmHg with exercise | ||
3. Excessive LVH in the absence of hypertension |
Table 11.6
ESC/EACTS indications for TAVR
ESC/EACTS recommendations: indications for TAVR | COR | LOE |
|---|---|---|
TAVR should only be undertaken with a multidisciplinary heart team including cardiologists, cardiac surgeons and other specialists if needed | I | C |
TAVR should only be performed with cardiac surgery on site | I | C |
TAVR is recommended in patients who meet an indication for AVR for AS who have a prohibitive surgical risk and a predicted post-TAVR survival ≥12 months and are likely to gain improvement in their quality of life | I | B |
TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk | IIa | B |
Special Populations with Severe Aortic Stenosis
Certain patient populations require special considerations when they suffer aortic stenosis. Patients that require additional diagnostic tools, exhibit increased likelihood of worse outcomes, or need alternative treatment plans fall into this category. These patients include
1.
Pregnant patients,
2.
Patients with low flow status with and without preserved left ventricular ejection fraction,
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