The American College of Cardiology collaborated with the American Association for
Thoracic Surgery, American Heart Association, American Society of Echocardiography,
European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of
Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions,
Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic
Resonance, and Society of Thoracic Surgeons to develop and evaluate Appropriate Use
Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS). This
is the first AUC to address the topic of AS and its treatment options, including surgical
aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR).
A number of common patient scenarios experienced in daily practice were developed
along with assumptions and definitions for those scenarios, which were all created
using guidelines, clinical trial data, and expert opinion in the field of AS. The
2014 AHA/ACC guideline for the management of patients with valvular heart disease:
a report of the American College of Cardiology/American Heart Association Task Force
on Practice Guidelines(1) and its 2017 focused update paper (2) were used as the primary
guiding references in developing these indications. The writing group identified 95
clinical scenarios based on patient symptoms and clinical presentation, and up to
6 potential treatment options for those patients. A separate, independent rating panel
was asked to score each indication from 1 to 9, with 1-3 categorized as "Rarely Appropriate,"
4-6 as "May Be Appropriate," and 7-9 as "Appropriate." After considering factors such
as symptom status, left ventricular (LV) function, surgical risk, and the presence
of concomitant coronary or other valve disease, the rating panel determined that either
SAVR or TAVR is Appropriate in most patients with symptomatic AS at intermediate or
high surgical risk; however, situations commonly arise in clinical practice in which
the indications for SAVR or TAVR are less clear, including situations in which 1 form
of valve replacement would appear reasonable when the other is less so, as do other
circumstances in which neither intervention is the suitable treatment option. The
purpose of this AUC is to provide guidance to clinicians in the care of patients with
severe AS by identifying the reasonable treatment and intervention options available
based on the myriad clinical scenarios with which patients present. This AUC document
also serves as an educational and quality improvement tool to identify patterns of
care and reduce the number of rarely appropriate interventions in clinical practice.