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Table 1. Indications for aortic valve implantation according to the ESC/EACTS and ACC/AHA
ESC/EACTS Guidelines ACC/AHA Guidelines
The choice for intervention must be based on careful individual TAVR is recommended for symptomatic patients with se-
evaluation of technical suitability and evaluating of risks and vere AS and high risk for SAVR, depending on patient spe-
benefits of each modality. In addition, the operators’ expertise cific procedural risk, values and preferences (I A)
and outcomes data for the given procedure must be taken into
account (I C)
Aortic valve implantation is recommended in patients who are not TAVR is recommended for symptomatic patients with se-
suitable for SAVR as assessed by the Heart vere AS, extremely high risk for SAVR, and predicted post-
Team (I B) procedure survival greater than 12 months (I A)
In patients who are at increased surgical risk (STS or EuroSCORE II TAVR is a reasonable alternative to SAVR for symptomatic
≥ 4% or logistic EuroSCORE I ≥ 10% or other risk factors not patients with severe AS and intermediate surgical risk,
included in these scores (frailty, porcelain aorta, post-radiation chest), depending on patient-specific procedural risk, values and
the choose between surgery or aortic valve implantation should be preferences (IIa B)
made by the Heart Team in consideration of individual patient
features, with aortic valve implantation being encouraged in elderly
patients suitable for transfemoral access (I B)
Aortic valve procedures should only be performed in centres with For severely symptomatic patients with bioprosthetic ste-
Cardiology Unit and Cardiovascular Surgery Unit on site and with nosis or regurgitation at high of prohibitive risk for reopera-
structured collaboration between the two, including a Heart Team tion, and in whom improvement in hemodynamics is antici-
(heart valve centres) pated, valve in valve TAVR is feasible (IIa B)
(IC)

ACC: American College of Cardiology; AHA: American Heart Association; AS: aortic stenosis; EACTS: European Association for Cardio-
Thoracic Surgery; ESC: European Society of Cardiology; STS: Society of Thoracic Surgeons Risk Score; TAVR: transcatheter aortic valve
replacement

risk) and procedural impediments (absent in low risk and minimal or possible in intermediate and high risk,
respectively). The fourth group (prohibitive risk) doesn’t consider STS risk score, but pre-operative risk of
mortality and morbidity at 1 year > 50%, ≥ 3 compromised major organ systems not to be improved postop-
[10]
eratively, severe frailty, or severe impediments linked to procedure .

According to this classification, TAVI is recommended in patients with prohibitive surgical risk and is con-
sidered a reasonable alternative to conventional surgery in those with high risk. In Table 1, indications for
TAVI according to the ESC/EACTS and ACC/AHA are reported.

HIGH-RISK PATIENTS
Untreated AS has been conventionally considered a terminal condition for patients refusing high-risk sur-
[11]
gical valve replacement or those deemed not operable candidates by treating physicians . Surgical aortic
valve replacement has demonstrated to improve symptoms and long-term prognosis; however, observational
studies identified subgroups of patients, such as those elderly or with reduced ejection fraction, that are at
increased surgical risk for procedural complications or death anyway . As regards these patients, a less in-
[12]
[8]
vasive treatment would be a desirable alternative and, for this reason, over the last decade TAVI has been
identified as the standard of care for high-surgical risk patients or for those considered inoperable by sur-
geons. TAVI has demonstrated the potential to decrease the morbidity associated with standard SAVR owing
to the avoidance of a median sternotomy, cardiopulmonary bypass and cardioplegic arrest. Nevertheless, the
selection process towards TAVI needs thoughtful consideration of risks and benefits of the procedure and a
[13]
comparison of these factors with alternative therapies . The EACTS/ESC Guidelines recommend four main
steps for patient selection before TAVI procedure: severity of valve stenosis and symptom confirmation, as-
sessment of the technical feasibility, exclusion of contraindications, and accurate clinical examination for
[14]
surgical risk assessment based on validated scores .

[16]
[15]
Also given these guidelines, a EuroSCORE > 20% or a STS > 10% has been used to identify “high-risk”
patients. It has also been recognized that factors such as frailty, associated with adverse outcomes and actu-