Faculty Bibliography

The American College of Cardiology collaborated with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons to develop and evaluate Appropriate Use Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS). This is the first AUC to address the topic of AS and its treatment options, including surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). A number of common patient scenarios experienced in daily practice were developed along with assumptions and definitions for those scenarios, which were all created using guidelines, clinical trial data, and expert opinion in the field of AS. The 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(1) and its 2017 focused update paper (2) were used as the primary guiding references in developing these indications. The writing group identified 95 clinical scenarios based on patient symptoms and clinical presentation, and up to 6 potential treatment options for those patients. A separate, independent rating panel was asked to score each indication from 1 to 9, with 1-3 categorized as "Rarely Appropriate," 4-6 as "May Be Appropriate," and 7-9 as "Appropriate." After considering factors such as symptom status, left ventricular (LV) function, surgical risk, and the presence of concomitant coronary or other valve disease, the rating panel determined that either SAVR or TAVR is Appropriate in most patients with symptomatic AS at intermediate or high surgical risk; however, situations commonly arise in clinical practice in which the indications for SAVR or TAVR are less clear, including situations in which 1 form of valve replacement would appear reasonable when the other is less so, as do other circumstances in which neither intervention is the suitable treatment option. The purpose of this AUC is to provide guidance to clinicians in the care of patients with severe AS by identifying the reasonable treatment and intervention options available based on the myriad clinical scenarios with which patients present. This AUC document also serves as an educational and quality improvement tool to identify patterns of care and reduce the number of rarely appropriate interventions in clinical practice.

AIMS:Radiation exposure and prolonged procedure time continue to limit the complexity of CTO-PCI procedures attempted. This study aimed to assess the impact of radiation dose-limiting equipment on radiation dosage and fluoroscopic time in chronic total occlusion (CTO) percutaneous coronary interventions (PCI). METHODS AND RESULTS:Retrospective clinical and dosimetric data from diagnostic catheterisations (DXC) and CTO-PCI procedures performed on one of three variants of interventional fluoroscopic equipment were collected. Fluoroscopic time, air kerma, kerma area product and contrast utilisation were stratified by procedure type and compared among equipment types. To standardise comparisons among equipment configurations, an efficiency index (EI) was calculated. In total, 2,947 DXC and 276 CTO-PCI procedures were studied. For DXC, radiation dose (AK) decreased by 45% (despite modest increases in fluoroscopic time [FT]) between the reference (REF) and moderately dose-optimised (ECO) machines. A further 20% decrease in AK was observed on the highly dose-optimised machine (CLA). For CTO-PCI, AK declined by almost half (48%), despite a 76% increase in FT and higher procedural success rates (69.8% versus 83.0%) between REF and CLA. • Conclusions: Novel dose-optimised fluoroscopic equipment allows longer FT with a decrease in radiation dose to both patient and operator. This should allow operators to undertake increasingly longer and more complex procedures and reduce operators' lifetime irradiation.