Patient Selection
ÎÎAVR 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.
ÎÎPatient selection for AVR for AS is well outlined by ACCF/AHA and ESC
guidelines. (See SOURCE list)
ÎÎThe 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
ÎÎRisk 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.
ÎÎ30%-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
ÎÎAlthough age itself is a risk factor for adverse outcome, it is not a
contraindication to AVR even in the very elderly.
ÎÎPatients undergoing surgical AVR with significant (50%-70%) stenoses
in major coronary arteries should be treated with concomitant coronary
artery bypass graft (CABG).
ÎÎTreatment of aortic regurgitation (AR), mitral regurgitation (MR) and
tricuspid regurgitation (TR) in patients undergoing AVR should be
undertaken using standard criteria.
ÎÎPulmonary hypertension (PH) associated with critical AS portends a poor
prognosis and is associated with an increased risk of sudden cardiac
death.
ÎÎIn 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.
ÎÎOutflow tract gradients (hypertrophic cardiomyopathy) detected by
echocardiography dictate open AVR, which allows myomectomy.
