Table 3

Severe AS: High- or Extreme-Risk Patients

IndicationAppropriate Use Median Score (1–9)
No InterventionBAV (as Bridge or Palliative Care)TAVRSAVR
Due to Multiple Comorbidities
30.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • Health status seems to be influenced more by comorbidities than by AS

  • Anticipated life expectancy >1 y

M (4)M (5)A (7)M (4)
31.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • Health status seems to be influenced more by AS than by comorbidities

  • Anticipated life expectancy >1 y

R (2)M (4)A (8)M (5)
32.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • Health status seems to be influenced more by comorbidities than by AS

  • Anticipated life expectancy <1 y

A (8)M (5)R (3)R (1)
33.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • Health status seems to be influenced more by AS than by comorbidities

  • Anticipated life expectancy <1 y

M (6)M (5)M (4)R (2)
34.
  • Severe symptomatic AS

  • STS-PROM >15%

  • Health status seems to be influenced more by comorbidities than by AS

  • Anticipated life expectancy >1 y

M (6)M (5)M (6)R (2)
35.
  • Severe symptomatic AS

  • STS-PROM >15%

  • Health status seems to be influenced more by AS than by comorbidities

  • Anticipated life expectancy >1 y

M (4)M (5)A (7)R (3)
36.
  • Severe symptomatic AS

  • STS-PROM >15%

  • Health status seems to be influenced more by comorbidities than by AS

  • Anticipated life expectancy <1 y

A (8)M (4)R (3)R (1)
37.
  • Severe symptomatic AS

  • STS-PROM >15%

  • Health status seems to be influenced more by AS than by comorbidities

  • Anticipated life expectancy <1 y

A (7)M (5)R (3)R (1)
With Frailty or Disability
38.
  • Severe AS (Vmax 4–4.9 m/s)

  • STS-PROM 8%–15%

  • Frail

  • No chest pain or syncope

  • Fatigue but no shortness of breath

  • Normal BNP

M (5)M (4)M (5)R (3)
39.
  • Severe AS (Vmax 4–4.9 m/s)

  • STS-PROM 8%–15%

  • Frail

  • No chest pain or syncope

  • Fatigue but no shortness of breath

  • BNP elevated

M (4)M (4)A (7)M (4)
40.
  • Very severe AS (Vmax ≥5 m/s)

  • STS-PROM 8%–15%

  • Frail

  • No chest pain or syncope

  • Fatigue but no shortness of breath

  • Normal BNP

M (4)M (5)A (7)M (4)
41.
  • Very severe AS (Vmax ≥5 m/s)

  • STS-PROM 8%–15%

  • Frail

  • No chest pain or syncope

  • Fatigue but no shortness of breath

  • BNP elevated

R (3)M (5)A (8)M (4)
42.
  • Severe AS (Vmax ≥4 m/s)

  • STS-PROM 8%-15%

  • Dependent in >3 activities of daily living (bathing, dressing, eating, ambulating, toileting, transferring)

  • Shortness of breath

M (5)M (5)M (5)R (2)
43.
  • Severe AS (Vmax ≥4 m/s)

  • STS-PROM 8%–15%

  • Dependent in >3 activities of daily living (bathing, dressing, eating, ambulating, toileting, transferring)

  • Fatigue but no shortness of breath

M (6)M (4)M (4)R (2)
Due to Anatomy
44.
  • Severe symptomatic AS

  • Porcelain aorta or hostile chest

  • Otherwise high or intermediate surgical risk due to comorbidities

R (2)M (4)A (8)R (3)
45.
  • Severe symptomatic AS

  • Porcelain aorta or hostile chest

  • Otherwise low surgical risk due to comorbidities

R (1)R (3)A (8)M (4)
Due to Specific Comorbidities
46.
  • Severe AS

  • STS-PROM 8%–15%

  • Oxygen-dependent lung disease

  • Shortness of breath

  • BNP normal

M (5)M (5)A (7)R (3)
47.
  • Severe AS

  • STS-PROM 8%–15%

  • Oxygen-dependent lung disease

  • Shortness of breath

  • BNP elevated

R (3)M (5)A (8)M (4)
48.
  • Severe symptomatic AS

  • STS-PROM >15%

  • End-stage renal disease

  • Longstanding dialysis, not a renal transplant candidate

  • Multiple comorbidities

M (5)M (4)M (6)R (2)
49.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • End-stage renal disease

  • Short time on dialysis

  • Renal transplant candidate

  • Nondiabetic, nonhypertensive etiology

R (3)R (3)A (7)A (7)
50.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • Cirrhosis with MELD >14

M (5)M (5)A (7)R (2)
51.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • Cirrhosis with MELD <10

R (3)M (4)A (7)M (5)
52.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • Moderate to severe dementia (minimally oriented)

  • Symptoms described by family but not verbalized by the patient

A (8)R (3)R (2)R (1)
53.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • Malignancy

  • Life expectancy >1 year

M (5)M (4)A (7)M (6)
54.
  • Severe symptomatic AS

  • STS-PROM 8%–15%

  • Malignancy

  • Life expectancy <1 y

A (7)M (5)R (2)R (1)

A = Appropriate; AS = aortic stenosis; BAV = balloon aortic valvuloplasty; BNP = b-type natriuretic peptide; M = May Be Appropriate; MELD = model for end-stage liver disease; R = Rarely Appropriate; SAVR = surgical aortic valve replacement; STS-PROM = Society of Thoracic Surgeons predicted risk of mortality score; TAVR = transcatheter aortic valve replacement; Vmax = peak aortic valve velocity.