Appropriate Use Criteria for the Management of Aortic Stenosis: Insight From the Japanese Expert Panel

BACKGROUND: The indication for transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) significantly varies among physicians and institutions. OBJECTIVES: This study aims to develop a set of appropriate use criteria for AS management to assist physicians in decision-making. METHODS: The RAND-modified Delphi panel method was used. A total of >250 common clinical scenarios were identified in terms of whether to perform the intervention for AS and the mode of intervention (surgical aortic valve replacement vs TAVR). Eleven nationally representative expert panelists independently rated the clinical scenario appropriateness on a scale of 1-9, as “appropriate” (7-9), “may be appropriate” (4-6), or “rarely appropriate” (1-3); the median score of the 11 experts was then assigned to an appropriate-use category. RESULTS: The panel identified 3 factors that were associated with a rarely appropriate rating in terms of performing the intervention: 1) limited life expectancy; 2) frailty; and 3) pseudo-severe AS on dobutamine stress echocardiography. Clinical scenarios that were deemed rarely appropriate for TAVR were also identified: 1) patients with low surgical risk and high TAVR procedural risk; 2) patients with coexistent severe primary mitral regurgitation or rheumatic mitral stenosis; and 3) bicuspid aortic valve that was not suitable for TAVR. Importantly, any TAVRs for patients who were older than 75 years of age were not rated as rarely appropriate. CONCLUSIONS: These appropriate use criteria provide a practical guide for physicians regarding clinical situations commonly encountered in daily practice and elucidates scenarios deemed rarely appropriate that are clinical challenges for TAVR.