New AUC Document Gives a Multimodality Take on Imaging in Valvular Heart Disease

A likely trendsetter. That’s how Cleveland Clinic cardiologist and professor of medicine Milind Desai, MD, characterizes a newly released document on appropriate use criteria (AUC) for imaging patients with valvular heart disease.

Rather than exploring the benefits of a single imaging modality, this comprehensive document, published in the September 26 Journal of the American College of Cardiology, mirrors the clinical decision-making process by providing information to help physicians select the modality that will provide the greatest benefit in multiple scenarios.

“It should help clinical decision-making in many complex scenarios where there is a void in data-driven guidelines,” says Dr. Desai, who serves on the American College of Cardiology (ACC) Appropriate Use Criteria Task Force and was a member of the rating panel for the new AUC document.

The document was the brainchild of the ACC and has been endorsed by nine other leading subspecialty societies in cardiology, cardiothoracic surgery and radiology.

“The big difference with these criteria — as well as with a companion AUC document on structural heart disease that will follow shortly — is that all relevant imaging modalities are included: echocardiography, nuclear imaging, invasive angiography, CT and MRI,” adds Cleveland Clinic cardiovascular imaging specialist and professor of radiology Paul Schoenhagen, MD, who served on the five-member writing group for the AUC document. “When you are faced with a clinical problem, this will help you choose the test with the highest likelihood of providing a useful answer.”

Imaging recommendations for valvular and structural heart disease were initially contained in a single document, but its size proved unwieldy, prompting its division into separate reports for valvular and structural imaging. “The documents overlap, but they had to be separated,” says Dr. Schoenhagen, who represented the Society of Cardiovascular Computed Tomography in the writing group.

A process driven by clinical scenarios

Traditional guidelines are written using a process that involves reviewing existing literature and assigning scientific relevance to findings.

In contrast, this AUC document began with a writing group of five physicians representing five diverse cardiovascular and radiology societies to establish various clinical scenarios involving imaging. A larger rating panel, which included Dr. Desai, then categorized each recommendation into one of three groups:

• “Appropriate”
• “May be appropriate”
• “Rarely appropriate”

The writing and rating groups went back and forth for about two years before producing a final set of recommendations for the use of various imaging techniques in the evaluation and management of patients with valvular and structural heart disease.

Recommendations across 92 scenarios

The final AUC document on valvular disease rates the appropriateness of imaging tests in 92 different scenarios presented across three sections and eight tables. The three sections focus on the initial evaluation for valvular heart disease, evaluation in patients who have undergone prior testing, and evaluation before, during and after transcatheter intervention (see Figure). The full gamut of patients is addressed, from those with minimal to no symptoms to those with worsening disease. It also covers follow-up imaging for various degrees of disease severity and imaging after valve replacement and repair.

Figure. Imaging studies throughout the course of management for transcatheter aortic valve replacement (TAVR). Left panel: Pre-TAVR echocardiography demonstrating a severely calcified aortic valve with restricted leaflet opening, consistent with severe aortic stenosis (see Table 7A from AUC document). Middle panel: Intraprocedural angiographic image showing the deployed TAVR valve/stent (see Table 7B from AUC document). Right panel: Three-month follow-up CT image showing mild leaflet thickening of the anterior cusp of the TAVR valve (see Table 7C from AUC document).

A premium on practicality

“I think this document will be very useful for clinical practitioners,” says Cleveland Clinic cardiologist Allan Klein, MD, who wasn’t involved with drafting or rating the recommendations but reviewed the document as President of the American Society of Echocardiography, one of the organizations endorsing the publication.

Dr. Klein’s choices for scenario-specific recommendations that stand out include:

• The pre-, intra- and postprocedural roles of transthoracic echo, CT and 3-D transesophageal echo in transcatheter aortic valve replacement (TAVR)
• Imaging guidance in percutaneous mitral valve repair
• The use of low-dose dobutamine stress echocardiography to evaluate patients with severe, symptomatic aortic stenosis with low flow/low gradient and depressed left ventricular ejection fraction

“Much of this is common sense, but it has been put in a practical format that clinicians can use as a reference when deciding which tests to order,” says Dr. Klein.

Why this document matters

With CMS and other payers increasingly tying reimbursement to AUC, establishing a consensus on which procedures are appropriate for specific diseases is a matter of financial survival for providers.

“Imaging is a significant contributor to healthcare costs, so it’s understandable that there’s interest in ensuring that when a test is ordered, it is necessary and appropriate,” says Dr. Schoenhagen. “Documents like these summarizing the expert opinion of cardiologists and radiologists will ensure that patients receive imaging tests with the greatest clinical benefit at the lowest cost.”