Surgeons, Interventionalists Collaborate on Guidelines for Management of Aortic Stenosis

With transcatheter aortic valve replacement (TAVR) becoming more commonplace in the United States, surgeons and interventionalists have worked together to publish updated clinical practice guidelines on behalf of the Society of Thoracic Surgeons (STS) to address major developments in the evaluation and management of patients with aortic valve disease. The executive summary, published in the April 2013 issue of Annals of Thoracic Surgery, focuses on a multidisciplinary heart team approach.

In writing the guidelines, Lars G. Svensson, MD, PhD, of the Cleveland Clinic (Cleveland, OH), and colleagues representing the STS set out to:

• Outline pros and cons of treatment options
• Discuss areas where further research is needed
• Provide technical guidelines for aortic valve and aortic surgery
• Provide background for recommended quality measures and suggest further quality measures
• Present the new STS valve data collection variables that address issues related to the preoperative testing and technical aspects of aortic valve surgery

Up-to-Date Recommendations

More specifically, the writing committee homed in on TAVR with a balloon-expandable valve and made recommendations based on the most recent research findings. Committee members stressed the need for a multidisciplinary heart team approach and endorsed the percutaneous procedure for inoperable patients with an expected survival longer than 1 year or operative patients with a high predicted surgical mortality. In addition, they said that TAVR can be performed in either a hybrid operating room or a well-equipped cath lab dedicated to TAVR, and is best done transfemorally when access is suitable.

The committee stressed that TAVR candidates should undergo a surgical assessment by a heart team. Objective risk measures like the EuroScore and the STS risk score, while beneficial, “should be used to document risk but should not be used independent of a surgical assessment.”

In addition, after TAVR, patients should be prescribed dual antiplatelet therapy with clopidogrel and aspirin for between 3 and 6 months, with aspirin continued indefinitely, according to Dr. Svensson and colleagues. They added that all centers performing TAVR should report their results to a national database.

Advent of TAVR Has Improved Overall Treatment

“For cardiologists and cardiac surgeons there have been few options and no guidelines on how to manage the high-risk, previously inoperable, patients,” Dr. Svensson and colleagues write, adding that the PARTNER and ongoing CoreValve trials have added greatly to the field. “Previous studies have suggested that between 38% (Europe) and two-thirds (Southern California) of patients with severe aortic valve stenosis go untreated,” they add. “With the advent of TAVR both the traditionally open aortic valve replacement procedures and balloon valvuloplasty have [similarly] evolved.”

In an interview with TCTMD, Philippe Généreux, MD, of Columbia University Medical Center (New York, NY), said “these are great guidelines that mirror PARTNER 1a and 1b pretty well [and that show] that TAVR has a place in the algorithm of treatment.”

He praised the committee’s emphasis on the heart team approach both in the evaluation and treatment phases, as well as the slight “move away from the dogma of risk cohorts. They recognize that STS and EuroScore are not perfect tools to screen and risk-stratify patients,” he said, adding that the heart team can sometimes do this much better.

With regard to dual antiplatelet therapy, Dr. Généreux said it was appropriate for the guidelines to align their recommendations with what was used in PARTNER. However, this “still needs to be proven by a trial or other level or evidence. That’s empirical right now,” he noted.

A New Era of Cross-Specialty Collaboration

In addition, Dr. Généreux was impressed with the recommendation that TAVR could be performed in a dedicated cath lab. With the miniaturization of the device and simplification of the procedure, this option seems more feasible, he indicated. Moreover, hybrid rooms are quite expensive. This endorsement of cath labs “will allow centers where both surgeons and interventional cardiologists are part of the heart team to proceed in a well-equipped cath lab room because not everyone can afford a hybrid room,” he observed.

He also said the priority put on transfemoral TAVR will ultimately benefit patients and potentially change practice, especially given that many centers still perform transapical TAVR in up to half of cases. “I think that sites that are doing transapical [to the same extent] as transfemoral should move away from that and do transfemoral [as a first choice],” he noted.

Mainly, Dr. Généreux stressed the importance of surgeons and interventional cardiologists working together to create these guidelines. “Clearly there is recognition that this disease is a hybrid disease and that we need both surgeons and cardiologists to treat it,” he concluded. “In 2013 it would have been inappropriate to include only 1 or the other in the management of this disease because both options are available, and as we move forward both options are going to be equally performed.”

Note: Coauthor Martin B. Leon, MD, is a faculty member of the Cardiovascular Research Foundation, which owns and operates TCTMD.

 

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Source:
Svensson LG, Adams DH, Bonow RO, et al. Aortic valve and ascending aorta guidelines for management and quality measures: Executive summary. Ann Thorac Surg. 2013;95:1491-1505.

 

 

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