Algorithms and Criteria for Transcatheter Aortic Valve Replacement Patient Selection: Current Status and Future Trends

The advent of transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis and established a life-prolonging therapy in patients that are not operative candidates. It is also approved for high-risk surgical candidates and shows effectiveness comparable to surgical aortic valve replacement (SAVR). The inoperable and high-risk groups represent two parallel but partly divergent populations. In those deemed inoperable, decisions revolve around offering TAVR, palliation, or rehabilitation. These are based primarily on the likelihood of procedural success and clinical benefit, with a careful assessment of the source of their debility and features that underlie extreme surgical risk. In patients that are at high-risk for SAVR, determination of the most favorable route of valve replacement is guided by comparative procedural characteristics, the need for coincident interventions, and presumed ability for rehabilitation. These decisions are inherently difficult and currently rely on imperfect but developing risk assessment systems. Given the complexity of these decisions and patient population, the TAVR experience has underscored the value of a multi-disciplinary approach to advanced cardiovascular disease.