Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline

Vandvik, Per Olav; Otto, Catherine M.; Siemieniuk, Reed; Bagur, Rodrigo; Guyatt, Gordon; Lytvyn, Lyubov; Whitlock, Richard; Vartdal, Trond; Brieger, David; Aertgeerts, Bert; Price, Susanna; Foroutan, Farid; Shapiro, Michael A.; Mertz, Ray; Spencer, Frederick A.

doi:10.1136/bmj.i5085

Cited by 69 publications

(71 citation statements)

References 17 publications

(23 reference statements)

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“…The panel followed the BMJ Rapid Recommendations procedures for creating a trustworthy recommendation,2021 including using the GRADE approach to critically appraise the evidence and translate it to recommendations (see appendix 2 on bmj.com) 4. The panel considered the benefits, harms and burdens of DAPT versus single antiplatelet therapy, the quality (certainty) of the evidence for each outcome, variations in patient values and preferences, as well as acceptability and feasibility 22.…”

Section: Current Practicementioning

confidence: 99%

Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline

Prasad

Siemieniuk

Qin

et al. 2018

BMJ

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What is the role of dual antiplatelet therapy after high risk transient ischaemic attack or minor stroke? Specifically, does dual antiplatelet therapy with a combination of aspirin and clopidogrel lead to a greater reduction in recurrent stroke and death over the use of aspirin alone when given in the first 24 hours after a high risk transient ischaemic attack or minor ischaemic stroke? An expert panel produced a strong recommendation for initiating dual antiplatelet therapy within 24 hours of the onset of symptoms, and for continuing it for 10-21 days. Current practice is typically to use a single drug

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Section: Current Practicementioning

confidence: 99%

Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline

Prasad

Siemieniuk

Qin

et al. 2018

BMJ

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“…Importantly, should the decision for revascularization be taken, we strongly recommend the use of radial artery approach for PCI as the default access in patients undergoing TAVI, whether a priori or concomitant. Indeed, the use of the radial access site (compared to femoral) in PCI is associated with a significant reduction in major vascular and bleeding complications (8-10) particularly when the transfemoral approach is the preferred access site for TAVI (11).…”

Section: Revascularization Strategiesmentioning

confidence: 99%

Revascularizing coronary artery disease in patients undergoing transcatheter aortic valve implantation

2018

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Coronary artery disease (CAD) is common among p a t i e n t s u n d e r g o i n g t r a n s c a t h e t e r a o r t i c v a l v e implantation (TAVI) with a prevalence of up to 75%, and no clear recommendations around its treatment (1) and conflicting evidence around whether to perform coronary revascularization or not. Moreover, the role of revascularization on long-term morbidity and mortality is still not clear in octogenarians (2). Piccolo and colleagues (3) have provided an interesting editorial comment on our work (1), and further pointed out controversies with regards to revascularization of patients with CAD and undergoing TAVI.The authors also commented on their own results (4), based on an elegant age-and gender-matched analysis where they found a significant increase in the composite of cardiovascular death, myocardial infarction, or stroke at 1-year among TAVI patients with CAD. However, it should be highlighted that the authors found a similar risk of ischemic events during TAVI procedures among patients without CAD as compared to the matched population with CAD. Even when the complexity and severity of CAD is considered and the SYNTAX score is used to stratify CAD severity, the evidence is mixed with regards to mortality outcomes (5,6). Moreover, emerging data on completeness of revascularization is also conflicting. Indeed, while Van Mieghem and colleagues (7) suggested no influence of completeness of revascularization on mortality, a recent large analysis showed that incompleteness of revascularization and more severe CAD were independent predictors of mortality (6).Our findings indicate no benefit in 30-day and 1-year outcomes with a revascularization strategy. Notably, revascularized patients were at higher-risk of major vascular complications, although data were derived from percutaneous coronary intervention (PCI) undertaken through the transfemoral approach and much of the data analysed was subject to the inherent limitations of observational registries such as selection biases and unmeasured confounding. Revascularization strategiesIn terms of symptoms assessment, it is often difficult to rely upon them in this population and tools conventionally used in patients with stable angina to guide revascularization (i.e., fractional flow reserve) are still not well validated and widely used in the setting of severe aortic stenosis. Hence, it is reasonable to percutaneously revascularize ostial or

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“…The BMJ Rapid Recs 27 provide age-stratified evidence tables and decision aids to assist in selection of a TAVI versus SAVR for treatment of severe AS in intermediate-risk patients. We have limited evidence for TAVI durability beyond 5 years2; thus, the expected remaining years of life and patient expectations become critically important in decision-making.…”

Section: The Prosthetic Valve Durability To Life Expectancy Ratiomentioning

confidence: 99%

Importance of the valve durability-life expectancy ratio in selection of a prosthetic aortic valve

Bagur

Pîbarot

Otto

2017

Heart

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Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline

Abstract: In patients with symptomatic severe aortic stenosis but at lower risk of perioperative death, how do minimally invasive techniques compare with open surgery? Prompted by a recent trial, an expert panel produced these recommendations based on three linked rapid systematic reviews

Cited by 69 publications

References 17 publications

Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline

Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline

Revascularizing coronary artery disease in patients undergoing transcatheter aortic valve implantation

Importance of the valve durability-life expectancy ratio in selection of a prosthetic aortic valve

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