Management of severe aortic stenosis¹

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Medical Therapy

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sAVR
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sAVR or TAVI
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Re-evaluate in
6 months or when symptoms occur

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Is the patient symptomatic?

Yes No

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Does the patient have any comorbidity or general condition that make benefit unlikely?

Yes No

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Is the patient’s LVEF <50%

Yes No

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Is the patient at low risk and has no other characteristics that favour TAVI?

Yes No

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Is the patient physically active?

Yes No

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Carefully evaluate the patient’s technical suitability and risk-benefit ratio of intervention modes with the Heart Team

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Excercise test:
Does the patient have symptoms or a fall in BP below baseline?

Yes No

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Does the patient have risk factors and low individual surgical risk?

Yes No

sAVR

	Tissue valves	Mechanical valves
Long-term blood thinner required	No¹	Yes Daily blood thinner medication and regular blood tests for rest of life¹
Valve longevity / durability	Approximately 12–15 years,* depending on type of valve, patient characteristics, and other factors² RESILIA tissue** has been shown in animal studies to have less calcium build-up, potentially allowing the valve to last longer^†3	Over 20 years⁴
Lifestyle limitations	No	Yes Limits active lifestyle due to use of blood thinners⁵
Dietary restrictions	Yes May need to reduce calcium intake^6,7	Yes May need to reduce foods high in vitamin K or foods that may increase the effect of blood-thinning medicines^6,7
Noticeable sounds from valve	No	Yes Clicking sound as valve opens and closes
Pregnancy considerations	No No known pregnancy complication risk¹	Yes High pregnancy complication risks due to use of blood thinners¹

sAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation

*Some tissue valves such as the PERIMOUNT valve have been shown to last up to 19.7 years⁸

** No clinical data are available that evaluate the long-term impact of RESILIA tissue in patients

† RESILIA tissue has not been studied for long term results in patients

References:

1. Baumgartner H, Falk V, Bax JJ, et al. Eur Heart J. 2017;38(36):2739–2791.
2. Applegate PM, Boyd WD, Applegate Ii RL, et al. J Biomed Res. 2017;31(5):373–376.
3. Flameng W, Verbeken E, Meuris B. J Thorac Cardiovasc Surg. 2015;149:340–345.
4. Rajput FA, Zeltser R. Aortic Valve Replacement. [Updated 2020 Aug 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537136/.
5. Mayo Clinic. Warfarin side effects: Watch for interactions. Available at: https://www.mayoclinic.org/diseases-conditions/deep-vein-thrombosis/in-depth/warfarin-side-effects/art-20047592. Accessed on 07/05/2021.
6. Nishimura RA, Otto CM, Bonow RO, et al. J Am Coll Cardiol. 2017;70(2):252–289.
7. Mayo Clinic. Warfarin diet: What foods should I avoid? Available at: https://www.mayoclinic.org/diseases-conditions/thrombophlebitis/expert-answers/warfarin/faq-20058443. Accessed on 14/04/2021.
8. Bourguignon T, Bouquiaux-Stablo AL, Candolfi P, et al. Ann Thorac Surg. 2015;99(3):831–837.

sAVR or TAVI

	TAVI (tissue valve)	sAVR (tissue valve)	sAVR (mechanical valve)
Valve-related considerations
Long-term blood thinner required	No¹	No¹	Yes Daily blood thinner medication and regular blood tests for rest of life¹
Valve longevity / durability	Approximately 5–10 years^2,3 As TAVI is a new technology, durability has not been fully established as yet²	Approximately 12–15 years,* depending on type of valve, patient characteristics, and other factors⁴ RESILIA tissue** has been shown in animal studies to have less calcium build-up, potentially allowing the valve to last longer^†5	Over 20 years⁶
Lifestyle limitations	No	No	Yes Limits active lifestyle due to use of blood thinners¹
Dietary restrictions	Yes May need to reduce calcium intake^7,8	Yes May need to reduce calcium intake^7,8	Yes May need to reduce foods high in vitamin K or foods that may increase the effect of blood-thinning medicines^7,8
Noticeable sounds from valve	No	No	Yes Clicking sound as valve opens and closes
Pregnancy considerations	No No known pregnancy complication risk¹	No No known pregnancy complication risk¹	Yes High pregnancy complication risks due to use of blood thinners¹
Procedure-related considerations
Recommended age for procedure	>80 years¹⁰ TAVI can also be considered for younger patients with a life expectancy <10 years¹⁰	<65 years¹⁰	<50 years¹⁰
Indication	Recommended in symptomatic AS patients who are not suitable for sAVR¹	Recommended in symptomatic AS patients with low surgical risk^‡1 In high risk patients,^†† the decision between sAVR and TAVI should be made by the Heart Team according to the individual patient characteristics (TAVI being favoured in elderly patients suitable for transfemoral access)	Recommended in symptomatic AS patients with low surgical risk^‡1 In high risk patients,^†† the decision between sAVR and TAVI should be made by the Heart Team according to the individual patient characteristics (TAVI being favoured in elderly patients suitable for transfemoral access)
Valve access considerations	Yes¹ Requires safe transfemoral access to the heart or alternative access routes	No Direct access to heart through open or minimally invasive heart surgery	No Direct access to heart through open or minimally invasive heart surgery
Visible scarring	Potential scarring on groin for transfemoral access^‡‡	Potential scarring on chest	Potential scarring on chest
Recovery time	Up to 3 months¹¹	Up to 3 months¹²	Up to 3 months¹²

AS, aortic stenosis; sAVR, surgical aortic valve replacement; STS, Society of Thoracic Surgeons; TAVI, transcatheter aortic valve implantation

* Some tissue valves such as the PERIMOUNT valve have been shown to last up to 19.7 years⁹

** No clinical data are available that evaluate the long-term impact of RESILIA tissue in patients

† RESILIA tissue has not been studied for long term results in patients

†† High surgical risk is defined as: STS or EuroSCORE II ≥4% or logistic EuroSCORE I ≥10% or other risk factors not included in these scores such as frailty, porcelain aorta, sequelae of chest radiation

‡ Low surgical risk is defined as: STS or EuroSCORE II <4% or logistic EuroSCORE I <10% and no other risk factors not included in these scores, such as frailty, porcelain aorta, sequelae of chest radiation

‡‡ Incision may be made near shoulder, ribs, or top of breastbone for other approaches if transfemoral is not suitable

References:

1. Baumgartner H, Falk V, Bax JJ, et al. Eur Heart J. 2017;38(36):2739–2791.
2. Blackman DJ, Saraf S, MacCarthy PA, et al. J Am Coll Cardiol. 2019;73(5):537–545.
3. Otto CM, Nishimura RA, Bonow RO, et al. Circulation. 2021;143;e35–e71(Suppl 3–13).
4. Applegate PM, Boyd WD, Applegate Ii RL, et al. J Biomed Res. 2017;31(5):373–376.
5. Flameng W, Verbeken E, Meuris B. J Thorac Cardiovasc Surg. 2015;149:340–345.
6. Rajput FA, Zeltser R. Aortic Valve Replacement. [Updated 2020 Aug 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537136/.
7. Nishimura RA, Otto CM, Bonow RO, et al. J Am Coll Cardiol. 2017;70(2):252–289.
8. Mayo Clinic. Warfarin diet: what foods should I avoid? Available at: https://www.mayoclinic.org/diseases-conditions/thrombophlebitis/expert-answers/warfarin/faq-20058443. Accessed on 14/04/2021.
9. Bourguignon T, Bouquiaux-Stablo AL, Candolfi P, et al. Ann Thorac Surg. 2015;99(3):831–837.
10. Otto CM, Nishimura RA, Bonow RO, et al. Circulation. 2021;143(5):e72–e227.
11. Guy’s and St Thomas’ NHS foundation trust. Having a TAVI for aortic stenosis: Going home after your TAVI. Available at: https://www.guysandstthomas.nhs.uk/resources/patient-information/cardiovascular/tavi-procedure-for-aortic-stenosis.aspx. Accessed on 20/04/21.
12. NHS. Aortic valve replacement: Recovery. Available at: https://www.nhs.uk/conditions/aortic-valve-replacement/recovery/. Accessed on 20/04/2021.

Management of severe aortic stenosis1

Management of severe aortic stenosis¹