ACC Publishes New Medical Guidance to Optimize TAVR

January 9, 2017—The American College of Cardiology (ACC) recently announced the publication of the 2016 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement (TAVR) in the Management of Adults With Aortic Stenosis. The new guidance is for clinicians and hospitals to use in assessing patients’ eligibility for TAVR, successfully performing the procedure, and providing appropriate follow-up. The document builds on recommendations set forth in the American Heart Association/ACC Guidelines for Management of Patients With Valvular Heart Disease. Catherine M. Otto, MD, is Chair of the Writing Committee for the guidance document, which is available online in Journal of the American College of Cardiology.

In the ACC announcement, Dr. Otto commented, "We set out to develop practice tools that could readily help centers—those that either want to start doing TAVR or that are already performing it—improve their processes, patient safety, and outcomes. The resulting checklists are designed as a starting point for managing patients who are being considered for TAVR. We also take clinicians through the steps that are needed to successfully perform the procedure, including what imaging tests are needed and how to ensure continuity of care when patients transition back to their treating physicians."

The authors noted that because of the rapid uptake of TAVR and changing patient management protocols, there is a need to implement best practices to ensure patients with severe, symptomatic aortic stenosis receive optimal care, especially as many are elderly and have complicating coexisting medical conditions.

The ACC advised that the guidance document provides a framework with four key sets of considerations:  

• Preprocedure considerations (eg, how to select and evaluate patients, engage in shared decision making, factor in other risk assessments)
• What imaging tests and measurements are needed and when
• Key issues and considerations in performing the TAVR procedure itself and managing complications
• Managing patients immediately after the procedure and for longer follow-up to ensure continuity of care

Dr. Otto stated, “TAVR is one of the most rapidly expanding technologies in medical care today, and as our population ages, we will see increasing numbers of people with severe aortic valve stenosis, so it is important to provide guidance on optimal use of this treatment. There is also a great deal of interest among patients who usually prefer TAVR over open heart valve surgery, if this option is appropriate for their medical condition.”

Dr. Otto added that even though a patient is referred for TAVR, it may not necessarily be the best choice. The new checklists help clinicians apply best practices, including determining if TAVR is appropriate in the context of individual patient considerations. The guidance also reinforces the central role of the heart valve team and the need for close collaboration with other clinicians, who should ideally have easy access to care plans, including what imaging tests are needed.

The writing group hopes that hospitals and valve centers will expand upon these resources to create their own internal checklists to use in patient care and update them over time to reflect the most recent clinical recommendations. Checklists could ideally be embedded into the electronic medical record to ensure that each patient has the appropriate diagnostic testing and follow-up care, as well as improve the safety of the TAVR procedure itself, according to the ACC announcement.