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Diagnosis and Patient Selection

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DIAGNOSIS AND PATIENT SELECTION Aortic Valve Stenosis Treatment
SAVR or TAVI

AORTIC STENOSIS IS A PROGRESSIVE DISEASE

Severe aortic senosis is usually defined as a valve area of ≤1.0 cm2 and a maximum velocity of ≥4.0 meters/second or mean pressure gradient ≥40 mm Hg.

Severe aortic stenosis is the result of leaflet calcification or congenital stenosis with severely reduced leaflet opening.1,2

Severe aortic stenosis makes the heart work harder

Severe aortic stenosis prevents your aortic valve leaflets from opening and closing properly. This makes your heart work harder to pump blood to the rest of your body. A diseased valve affects your health and limits your daily activities.

Symptoms of severe aortic stenosis include, but may not be limited to:

  • Chest pain
  • Dizziness
  • Fatigue
  • Out of breath
  • Irregular heartbeat

 

aotic valve
aotic valve

Aortic stenosis assessment

Cardiac auscultation

Purpose:
Detect heart valve disease.

Evaluates:

  • Heart sounds with stethoscope
  • Systolic ejection murmur

Attention: Low flow, low gradient (LF/LG) aortic stenosis cannot be detected by auscultation. Therefore, auscultation should not be relied on to exclude valve disease.

Exercise 
Testing

Purpose:
Detect symptoms and prognostic information during exercise.

Evaluates:

  • Risk stratification
  • Asymptomatic cases
  • Cardiac origin of dyspnoea

man on a machine

Echo-
Cardiography

Purpose:
Key diagnostic tool, which confirms aortic stenosis.
 

Evaluates:

  • Primary lesion, cause and severity of valve calcification
  • Hemodynamics, secondary lesions
  • Chamber size and function
  • Wall thickness

Computed Tomography

Purpose:
Detect aortic valve calcium load. Relevant for TAVI patient workup and pre-procedural planning.

Evaluates:

  • Calcium score
  • Exclusion of measurement errors in LF/LG
  • Coronary anatomy
  • Prosthesis sizing and access points

Cardiac 
Catherization

Purpose:
Provide additional information beyond initial findings and is restricted to patients with inconclusive non-invasive investigations.

Evaluates:

  • Pressures and cardiac output 
  • Assessment of ventricular performance
  • Severity of regurgitation

Indications is indicated in3

tavi clickable mapdiagnosis

Choice of Intervention3

clinical characteristics graph

ASPECTS TO BE CONSIDERED FOR THE DECISION BETWEEN SAVR AND TAVI3

Favors TAVI favors SAVR

PATIENT EVALUATION FOR TREATMENT

Essential questions in the evaluation of patients for valvular interventions

tavi clickable mapdiagnosis

PATIENT-CENTRED EVALUATION FOR INTERVENTION3

heart team decision

BP = Blood Pressure; EuroSCORE = European System for Cardiac Operative Risk Evaluation; LVEF = Left Ventricular Ejection Fraction; SAVR = Surgical Aortic Valve Replacement; STS-PROM= Society of Thoracic Surgeons - Predicted Risk of Mortality; TAVI = Transcatheter Aortic Valve Implantation;​
TF = Transfemoral; VHD = Valvular Heart Disease; CCT = Cardiac Computed Tomography; CMR = Cardiac Magnetic Resonance;  TOE = Transoesophageal Echocardiography; TTE = Transthoracic Echocardiography; AVA = Aortic Valve Area; BSA = Body Surface Area; CAD = Coronary Artery Disease; ESC = European Society of Cardiology; LV = Left Ventricle/Left Ventricular; LVOT = Left Ventricular Outflow Tract;​
a Class of recommendation.​
b Level of evidence.​
c, d, e  See tables and supplementary tables in ESC/EACTS guidelines published here: https://doi.org/10.1093/eurheartj/ehab395.​
The Heart Team recommendation should be discussed with the patient who can then make an informed treatment choice.​
f Adverse features according to clinical, imaging (echocardiography/CT), and/or biomarker assessment.​
g STS-PROM: http://riskcalc.sts.org/stswebriskcalc/#/calculate.​
h If suitable for procedure according to clinical, anatomical, and procedural factors (see table 6 in guidelines here: https://doi.org/10.1093/eurheartj/ehab395(opens new window)).​
i Life expectancy is highly dependent on absolute age and frailty, differs between men and women, and may be a better guide than age alone. There is wide varia-tion across Europe and elsewhere in the world (http://ghdx.healthdata.org/record/ihme-data/gbd-2017-life-tables-1950-2017).​
j Severe frailty = >2 factors according to Katz index59 (see section 3.3 for further discussion in guidelines here:  https://doi.org/10.1093/eurheartj/ehab395).​
k Via non-transfemoral approach.​
l According to the 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes.

References:

1

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. June 10, 2014;129(23):2440-2492.

2

Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of 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 Clinical Practice Guidelines. Circulation. June 20, 2017;135(25):e1159-e1195.

3

Alec Vahanian, Friedhelm Beyersdorf, Fabien Praz, Milan Milojevic, Stephan Baldus, Johann Bauersachs, Davide Capodanno, Lenard Conradi, Michele De Bonis, Ruggero De Paulis, Victoria Delgado, Nick Freemantle, Martine Gilard, Kristina H Haugaa, Anders Jeppsson, Peter Jüni, Luc Pierard, Bernard D Prendergast, J Rafael Sádaba, Christophe Tribouilloy, Wojtek Wojakowski, ESC/EACTS Scientific Document Group, 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), European Heart Journal, 2021;, ehab395, https://doi.org/10.1093/eurheartj/ehab395.

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The information on this web page is intended for educational purposes based on an identified need, it is not meant as a substitute for the Instructions for Use or product training, nor to constitute medical advice or in any way replace the ESC/EACTS guidelines or the independent medical judgment of a trained and licensed physician with respect to any patient needs or circumstances. Please refer to full ESC/EACTS guidelines for detailed explanation of patient populations. 

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