Guidance issued for decision making on transcatheter aortic valve replacement

The American College of Cardiology's expert decision consensus pathway addresses four areas: preprocedure evaluation, imaging modalities and measurements, key issues in performing the procedure, and recommendations for patient follow-up.


The American College of Cardiology recently released an expert decision consensus pathway to help guide decision making about transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis.

The pathway is based on expert consensus and provides point-of-care checklists and algorithms about TAVR in four sections: preprocedure evaluation, imaging modalities and measurements, key issues in performing the procedure, and recommendations for patient follow-up.

The decision pathway stressed the need for shared decision making and patient education when determining whether TAVR should be performed and recommended that initial assessment include evaluation of symptoms of aortic stenosis, disease severity, and standard clinical data, in addition to major cardiovascular and noncardiovascular comorbid conditions. The clinical team should also review echocardiographic measures of aortic stenosis severity, confirm disease severity, and perform additional imaging as needed, the pathway said. Frailty and disability should also be considered, along with cognitive function and futility.

An included checklist for post-TAVR clinical management outlined the key steps to be taken immediately after the procedure, including waking from sedation, postprocedure monitoring, pain management, early mobilization, and discharge planning.

Patients should be extubated early and their mental status should be monitored, the checklist said. Telemetry and vital signs should be monitored according to hospital protocol, intake and output should be monitored, and routine labs should be done. The access site should also be monitored for bleeding, hematoma, or pseudoaneurysm, the checklist said.

When planning discharge, clinicians should resume the patient's preoperative medications, plan the discharge location, order an echocardiogram and electrocardiogram before discharge, and schedule postdischarge clinic visits, according to the checklist.

The full decision pathway was published Jan. 4 by the Journal of the American College of Cardiology and is available online.