Patient Selection
����AVR is indicated in adults with severe, symptomatic, calcific stenosis of
a tricuspid aortic valve who have aortic and vascular anatomy suitable for
TAVR and a predicted survival >12 months:
������ TAVR is a reasonable alternative to surgical AVR in patients at high surgical risk.
������ TAVR is recommended in patients with prohibitive surgical risk.
����Patient selection for AVR for AS is well outlined by ACCF/AHA and ESC
guidelines. (See SOURCE list)
����The STS (http://riskcalc.sts.org/STSWebRiskCalc273/de.aspx) and
logistic EuroSCORE (http://www.euroscore.org/calc.html) are the most
commonly used risk algorithms for cardiac surgery.
STS
EuroSCORE
����Risk models need to be considered in concert with other methods of
risk assessment and the experience, knowledge, and expertise of the
physicians charged with rendering care.
����30%-40% of patients with severe AS do not undergo surgery owing to
advanced age, LV dysfunction, multiple coexisting conditions, and patient
preference or physician recommendation.
Associated Conditions
����Although age itself is a risk factor for adverse outcome, it is not a
contraindication to AVR even in the very elderly.
����Patients undergoing surgical AVR with significant (50%-70%) stenoses
in major coronary arteries should be treated with concomitant coronary
artery bypass graft (CABG).
����Treatment of aortic regurgitation (AR), mitral regurgitation (MR) and
tricuspid regurgitation (TR) in patients undergoing AVR should be
undertaken using standard criteria.
����Pulmonary hypertension (PH) associated with critical AS portends a poor
prognosis and is associated with an increased risk of sudden cardiac
death.
����In the low-flow/low-gradient AS patient, reduced contractility adversely
affects prognosis with surgical AVR. Operative mortality is as high as
20%. However, the 5-year survival is still reported to be better in patients
treated surgically.
����Outflow tract gradients (hypertrophic cardiomyopathy) detected by
echocardiography dictate open AVR, which allows myomectomy.
