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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n\u003Cp id=\u0022p-1\u0022\u003EThe 2014 American Heart Association\/American College of Cardiology guidelines for the management of patients with valvular heart disease include new definitions of disease severity and provide for a more in-depth assessment of risk and guidance on the choice of optimal therapy, particularly with respect to transcatheter aortic valve replacement. The format of the guidelines has also been improved to improve their use in clinical practice.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ETAVR\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESAVR\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emitral regurgitation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eaortic stenosis\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eheart team\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eguidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology \u0026amp; cardiovascular medicine guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Evalvular disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n\n\u003Cp id=\u0022p-2\u0022\u003EThe 2014 American Heart Association\/American College of Cardiology (ACC) guidelines for the management of patients with valvular heart disease [Nishimura RA et al. \u003Cem\u003EJ Thorac Cardiovasc Surg.\u003C\/em\u003E 2014; \u003Cem\u003ECirculation.\u003C\/em\u003E 2014; \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2014] are based on new data on the natural history of the disease, improvements in imaging that allow for better quantitation of stenosis and valve regurgitation, and better outcomes from surgical and catheter-based interventions. This new information allows for a lower threshold for intervention and extends treatments to sicker populations. Rick A. Nishimura, MD, Mayo Clinic College of Medicine, Rochester, Minnesota, USA, discussed key aspects of these guidelines.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003EStages of Disease\u003C\/h2\u003E\n\u003Cp id=\u0022p-3\u0022\u003ESimilar to the guidelines for heart failure, the 2014 valvular disease guidelines now consider disease stage. The authors identified 4 stages of increasing disease severity: stage A identifies individuals at risk for disease; stage B defines those with progressive disease; stage C includes individuals with severe but asymptomatic disease; and stage D is severe symptomatic disease. Severe disease is defined as the presence of symptoms or when natural history studies show a poor outcome.\u003C\/p\u003E\n\u003Cp id=\u0022p-4\u0022\u003EAccording to the guidelines, observation and monitoring are appropriate for patients with stage A or B disease. Stage C patients should be further risk stratified through an assessment of left ventricular (LV) function. High-risk stage C and stage D patients warrant intervention.\u003C\/p\u003E\n\u003Cp id=\u0022p-5\u0022\u003EWith aortic stenosis (AS) as an example, peak aortic jet velocity (AV-Vel) is a predictor of outcome in patients with AS and can be used to evaluate disease severity. Even among patients with asymptomatic AS, an AV-Vel\u2005\u0026gt;\u20054.0 m\/s is considered severe, while a velocity\u2005\u0026gt;\u20055.0 m\/s is considered very severe [Rosenhek R et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2010]. Stage C patients with decompensated LV function (end-diastolic pressure\u2005\u2265\u200540 mm) have worse outcomes. Intervention is recommended for patients with stage C disease and decompensated LV function and for those with stage D disease (severe symptomatic AS). The appropriate treatment for patients with stage C disease and compensated LV function is unclear.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003EGuidelines in the 21st Century\u003C\/h2\u003E\n\u003Cp id=\u0022p-6\u0022\u003EPracticing physicians need concise relevant bytes of knowledge synthesized by an expert that answer specific clinically relevant questions. Although the guidelines have the information, the format has not supported this need in the past. The 2014 valve disease guidelines were written with the needs of the practicing physician in mind. The taxonomy and evidence tables are based on how clinicians think (ie, diagnosis and testing, medical therapy, and treatment intervention). The ultimate objective is for the guidelines to contain supporting text with links to references and figures. Dr Nishimura believes that guidelines should be viewed as a living document for the 21st century where new knowledge can be added to the guidelines in a continuous stream.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003ELower Threshold for Intervention\u003C\/h2\u003E\n\u003Cp id=\u0022p-7\u0022\u003ECatherine M. Otto, MD, University of Washington, Seattle, Washington, USA, reviewed how the guidelines assess asymptomatic disease and low-flow AS. Although there is general agreement that it is appropriate to intervene once patients with AS become symptomatic (eg, angina, syncope, heart failure), prior to symptom onset, the clinician must balance the risk of monitoring and waiting with risk of aortic valve replacement (AVR).\u003C\/p\u003E\n\u003Cp id=\u0022p-8\u0022\u003EFor most patients with severe asymptomatic AS, monitoring is an acceptable course, but it is important to establish whether a patient is truly asymptomatic, whether his or her LV systolic function is normal, whether the AS is very severe or rapidly progressive, and what risks exist for intervention for this patient. An evaluation for symptoms includes a careful history and the identification of early diagnostic symptoms, such as decreased exercise tolerance, dyspnea, and exertional dizziness. If there is any uncertainty, stress testing is recommended. LV systolic function should be evaluated to determine the level of compensation, and it is important to remember that older patients are more likely to progress rapidly. Moderate or severe valvular calcification and an AV-Vel\u2005\u0026gt;\u20055.0 m\/s identify patients with a very poor prognosis [Rosenhek R et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2010; \u003Cem\u003ECirculation\u003C\/em\u003E. 2010]. Patients with asymptomatic severe AS, severe calcification, rapid progression, and LV ejection fraction (EF)\u2005\u0026lt;\u200550% will benefit from early AVR (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/5\/22\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u00222014 Timing of Intervention in Asymptomatic Patients With Severe ASAS, aortic stenosis; AVR, aortic valve replacement; BP, blood pressure; EF, ejection fraction; ETT, exercise tolerance test; ex, exercise; Vmax, velocity.Reproduced with permission from CM Otto, MD.Source: Nishimura RA et al. J Thorac Cardiovasc Surg. 2014.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1329559718\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;2014 Timing of Intervention in Asymptomatic Patients With Severe ASAS, aortic stenosis; AVR, aortic valve replacement; BP, blood pressure; EF, ejection fraction; ETT, exercise tolerance test; ex, exercise; V\u0026amp;lt;sub\u0026amp;gt;max\u0026amp;lt;\/sub\u0026amp;gt;, velocity.Reproduced with permission from CM Otto, MD.Source: Nishimura RA et al. \u0026amp;lt;em\u0026amp;gt;J Thorac Cardiovasc Surg\u0026amp;lt;\/em\u0026amp;gt;. 2014.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/5\/22\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/5\/22\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/5\/22\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16203\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003E2014 Timing of Intervention in Asymptomatic Patients With Severe AS\u003C\/p\u003E\n\u003Cp id=\u0022p-10\u0022\u003EAS, aortic stenosis; AVR, aortic valve replacement; BP, blood pressure; EF, ejection fraction; ETT, exercise tolerance test; ex, exercise; V\u003Csub\u003Emax\u003C\/sub\u003E, velocity.\u003C\/p\u003E\n\u003Cp id=\u0022p-11\u0022\u003EReproduced with permission from CM Otto, MD.\u003C\/p\u003E\n\u003Cp id=\u0022p-12\u0022\u003ESource: Nishimura RA et al. \u003Cem\u003EJ Thorac Cardiovasc Surg\u003C\/em\u003E. 2014.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-13\u0022\u003EThe guidelines also outline the timing and indications for intervention for the different hemodynamics and symptoms, such as low-flow AS (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E).\u003C\/p\u003E\n\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/5\/22\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022ACC\/AHA Valve Guidelines for Low-Flow ASACC, American College of Cardiology; AHA, American Heart Association; AS, aortic stenosis; AVAi, aortic valve area index; AVR, aortic valve replacement; DSE, dobutamine stress echocardiogram; EF, ejection fraction; SVI, stroke volume index; Vmax, velocity.Reproduced with permission from CM Otto, MD.Source: Nishimura RA et al. J Thorac Cardiovasc Surg. 2014.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1329559718\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;ACC\/AHA Valve Guidelines for Low-Flow ASACC, American College of Cardiology; AHA, American Heart Association; AS, aortic stenosis; AVA\u0026amp;lt;sub\u0026amp;gt;i\u0026amp;lt;\/sub\u0026amp;gt;, aortic valve area index; AVR, aortic valve replacement; DSE, dobutamine stress echocardiogram; EF, ejection fraction; SVI, stroke volume index; V\u0026amp;lt;sub\u0026amp;gt;max\u0026amp;lt;\/sub\u0026amp;gt;, velocity.Reproduced with permission from CM Otto, MD.Source: Nishimura RA et al. \u0026amp;lt;em\u0026amp;gt;J Thorac Cardiovasc Surg\u0026amp;lt;\/em\u0026amp;gt;. 2014.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/5\/22\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/5\/22\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/5\/22\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16204\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EACC\/AHA Valve Guidelines for Low-Flow AS\u003C\/p\u003E\n\u003Cp id=\u0022p-15\u0022\u003EACC, American College of Cardiology; AHA, American Heart Association; AS, aortic stenosis; AVA\u003Csub\u003Ei\u003C\/sub\u003E, aortic valve area index; AVR, aortic valve replacement; DSE, dobutamine stress echocardiogram; EF, ejection fraction; SVI, stroke volume index; V\u003Csub\u003Emax\u003C\/sub\u003E, velocity.\u003C\/p\u003E\n\u003Cp id=\u0022p-16\u0022\u003EReproduced with permission from CM Otto, MD.\u003C\/p\u003E\n\u003Cp id=\u0022p-17\u0022\u003ESource: Nishimura RA et al. \u003Cem\u003EJ Thorac Cardiovasc Surg\u003C\/em\u003E. 2014.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-18\u0022\u003EIn all cases, patient preferences and values should also be considered. As heart valves improve and procedural risks decrease, interventions are likely to be applied earlier in the course of disease.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003EPrimary vs Secondary MR\u003C\/h2\u003E\n\u003Cp id=\u0022p-19\u0022\u003EBlase A. Carabello, MD, Mount Sinai Beth Israel, New York, New York, USA, reminded the audience of the importance of understanding the difference between primary (organic) and secondary (functional) mitral regurgitation (MR). For primary MR, the triggers for intervention are EF\u2005\u0026lt;\u200560%, a pulmonary artery pressure of 50 mm Hg, or an end-systolic dimension of \u2265\u200540 mm. The emphasis should be on early durable repair. The development of even mild symptoms by the time of surgical referral is associated with reduced survival outcomes in patients with severe primary MR [David TE et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2013; Gillinov AM et al. \u003Cem\u003EAnn Thorac Surg.\u003C\/em\u003E 2010]. The best time to operate on these patients is before symptoms develop (provided valve pathology indicates that a repair is almost certain) and before LV end-systolic diameter reaches 40 mm, noted Dr Carabello [Tribouilloy C et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2009], or before EF declines to 60%.\u003C\/p\u003E\n\u003Cp id=\u0022p-20\u0022\u003EThe worse the pulmonary hypertension, the worse the short- and long-term survival is after MR surgery. Ghoreishi et al [\u003Cem\u003EJ Thorac Cardiovasc Surg.\u003C\/em\u003E 2011] found that in patients undergoing MR surgery, operative mortality was 2%, 3%, 8%, and 12% for those with no, mild, moderate, and severe preoperative pulmonary hypertension, respectively.\u003C\/p\u003E\n\u003Cp id=\u0022p-21\u0022\u003EDurable repair is a key for long-term survival. Most surgeons would consider surgery for a patient with no symptoms, normal LV function (EF\u2005\u0026gt;\u200560%), and an end-systolic dimension\u2005\u0026lt;\u200540 mm when there is a 95% likelihood of successful repair (class IIa).\u003C\/p\u003E\n\u003Cp id=\u0022p-22\u0022\u003ESecondary MR is virtually a separate disease from primary MR. Because it is secondary to severe LV dysfunction, it is associated with a poor prognosis; therefore, it is not surprising that no studies have shown improvement in survival following mitral valve surgery (MVS) compared with medical therapy or when MVS was added to bypass surgery [Benedetto U et al. \u003Cem\u003EJ Cardiovasc Med.\u003C\/em\u003E 2009]. For some patients with secondary MR, aggressive medical therapy, including cardiac resynchronization therapy, can be helpful [van Bommel RJ et al. \u003Cem\u003ECirculation.\u003C\/em\u003E 2011]. Although there is lack of survival benefit, patients do feel better after surgery as demonstrated by an improvement in NYHA class. Unlike for primary MR, in patients with secondary MR, surgery should be performed after all else has been tried.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-6\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003EThe Heart Team\u003C\/h2\u003E\n\u003Cp id=\u0022p-23\u0022\u003EMany practice guidelines\u2014including those of the European Society of Cardiology, the European Association for Cardio-Thoracic Surgery, the Centers for Medicare and Medicaid Services, and the ACC\u2014recommend the use of a multidisciplinary heart team consisting of a clinical\/noninvasive cardiologist, an interventional cardiologist, and a cardiac surgeon (class I, level C). Michael Mack, MD, Baylor Scott \u0026amp; White Health, Dallas, Texas, USA, supports this position and discussed how the use of such a team can help to ensure the selection of an optimal treatment strategy.\u003C\/p\u003E\n\u003Cp id=\u0022p-24\u0022\u003ECurrently there is a lack of consensus regarding the use of the heart team approach in terms of its definition, composition, desired goals, means of implementation, metrics of success, and unintended consequences [Coylewright M et al. \u003Cem\u003EJ Am Coll Cardiol.\u003C\/em\u003E 2015. In press]. Dr Mack described 5 reasons to have a heart team and 4 reasons not to (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\n\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16205\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16205\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16205\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-25\u0022 class=\u0022first-child\u0022\u003ESupport for and Against Utilizing a Heart Team\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-27\u0022\u003EThe makeup of a heart team can vary. The patient, cardiologist, surgeon, imagers, anesthesiologist, midlevel providers, and lead coordinator compose a typical team. In most practices, the team will evolve as needed, perhaps adding a neurologist or electrophysiologist.\u003C\/p\u003E\n\u003Cp id=\u0022p-28\u0022\u003EThe heart team should meet on a regular basis but also as needed. It should be organized into integrated practice units with the following characteristics:\u003C\/p\u003E\n\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\u003Cp id=\u0022p-29\u0022\u003EClinical and nonclinical personnel providing full-cycle care for a condition\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\u003Cp id=\u0022p-30\u0022\u003EDedicated multidisciplinary team\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\u003Cp id=\u0022p-31\u0022\u003EOutpatient, inpatient, rehabilitative care integrated\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\u003Cp id=\u0022p-32\u0022\u003ESingle administrative and scheduling unit\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\u003Cp id=\u0022p-33\u0022\u003EJoint accountability for outcomes and costs\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\n\u003Cp id=\u0022p-34\u0022\u003ETeam members should be in continuous contact via e-mail and text messaging. A fully integrated heart team offers the best patient outcomes at the best cost.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-7\u0022\u003E\n\u003Ch2 class=\u0022\u0022\u003ETiming of Intervention With TAVR\u003C\/h2\u003E\n\u003Cp id=\u0022p-35\u0022\u003EAs outcomes have improved, transcatheter aortic valve replacement (TAVR) has moved from being used only for the sickest patients toward being the first choice for AS therapy in most patients. Vinod H. Thourani, MD, Emory University, Atlanta, Georgia, USA, discussed the indications and timing of TAVR intervention.\u003C\/p\u003E\n\u003Cp id=\u0022p-36\u0022\u003ETAVR with medical therapy is superior to medical therapy alone in inoperable patients, equivalent to surgical aortic valve replacement (SAVR) in high-risk patients, and may be equivalent to SAVR in intermediate- and low-risk patients. It is generally agreed that a less invasive therapy is preferable to a more invasive approach when the 2 have equivalent outcomes; however, it is still necessary to assess whether the trade-off is worth the less invasive approach.\u003C\/p\u003E\n\u003Cp id=\u0022p-37\u0022\u003EOutcomes after SAVR are improving. One recent study in almost 142\u2005000 patients showed significantly improved in-hospital mortality (\u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.0001) in 80% of patients compared with the predicted risk [Thourani VH et al. \u003Cem\u003EAnn Thorac Surg.\u003C\/em\u003E 2015]. When a treatment course for AVR is being chosen, the level of organ dysfunction is also an important consideration, as multiple organ dysfunctions significantly decrease short- and long-term survival [Thourani VH et al. \u003Cem\u003EAnn Thorac Surg.\u003C\/em\u003E 2013].\u003C\/p\u003E\n\u003Cp id=\u0022p-38\u0022\u003EIn a head-to-head comparison of SAVR and TAVR in the PARTNER I trial, there were no differences in all-cause mortality, median survival, or mean gradient [Mack M et al. ACC 2015]. Recent reports from the PARTNER II trial, however, show significant improvement in 30-day mortality with the Sapien 3 valve [Kodali S et al. ACC 2015].\u003C\/p\u003E\n\u003Cp id=\u0022p-39\u0022\u003EDr Thourani sees TAVR becoming more common among intermediate-risk patients, with most low-risk patients receiving SAVR. More data are needed on the appropriate therapy for frail patients and for futility.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/5\/22.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlpg1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlpg1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlpg1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}