TAVR Procedure guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. ,Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. 
|Transcatheter Aortic Valve Replacement (TAVR) Procedure Guide Microchapters|
During the past 50 years, surgical aortic valve replacement (SAVR) was the standard of care for patients with severe AS. Global aging has raised concerns about safety and possibility of surgical procedure in old patients with associated co-morbidities. Transcatheter aortic valve replacement (TAVR) created a new era of safety for this population and enabled physicians to replace the stenotic valve with more certainty.
Preoperation evaluation, selecting the appropriate imaging modality, issues in TAVR procedure and patient follow up are the areas of more focused importance.
We will describe these factors based on the recent expert consensus for TAVR procedure.
The most important step is to define the severity of AS and appropriate patient that need TAVR. Severe symptomatic (Stage D) AS is considered as TAVR candidate.
Abbreviations: ΔP: mean gradient, Vmax: maximum aortic velocity, AVA: aortic valve area. AS: aortic stenosis, AR: aortic regurgitation.
|Severe symptomatic AS (stage D)|
|STAGE||DEFINITION||SYMPTOMS||VALVE ANATOMY||VALVE HEMODYNAMICS||HEMODYNAMIC CONSEQUENCES|
|D1||Symptomatic severe high-gradient AS||Severe calcification or congenital stenosis with severely reduced opening||
|D2||Symptomatic severe low-flow/low gradient AS with reduced LVEF||
||Severe calcification or congenital stenosis with severely reduced leaflet motion||
|D3||Symptomatic severe low gradient with normal LVEF||
||Severe calcification with severely reduced leaflet motion||
TAVR Pathway outline
CV: Cardiovascular, AVR: aortic valve replacement, AS: aortic stenosis, MR: Mitral regurgitation, AR: Aortic regurgitation, PAP: Pulmonary artery pressure, RV: right ventricle, CTA: CT angiography, PA: Pulmonary artery, TEE: Trans Esophageal Echocardiography, TTE: Trans Thoracic Echocardiography
Care Providing Team
Heart Valve Team
Patients with severe AS should be evaluated by a multidisciplinary Heart Valve Team when intervention is considered.
Team members include:
- Cardiology Valve Expert
- Cardiovascular Imaging Expert(s)
- Interventional Cardiologist
- Cardio-Thoracic Surgeon
- Cardiovascular Anesthesiologist
- Valve Clinic Care Coordinators
Their specific tasks are:
- Review the patient's medical condition and the severity of the valve abnormality
- Determine which interventions are indicated, technically feasible, and reasonable
- Discuss benefits and risks of these interventions with the patient and family, keeping in mind their values and preferences.
|Key Steps||Essential Elements||Additional Details|
|AS symptoms and severity||Symptoms
Echo and other imaging
|Baseline clinical data||Cardiac history
Physical exam and labs
|Prior cardiac interventions
Routine blood tests, PFTs
Access issues, other cardiac effects
Treat dental issues before TAVR
Recovery, transportation, post discharge planning
|Major CV comorbidity||Coronary artery disease||Coronary angiography|
|LV systolic dysfunction||LV ejection fraction|
|Concurrent valve disease||Severe MR or MS|
|Pulmonary hypertension||Assess pulmonary pressures|
|Aortic disease||Porcelain aorta (CT scan)|
|Peripheral vascular disease||Prohibitive re-entry after previous open heart surgery (CT scan)
|Major non CV comorbidity||Malignancy||Remote or active, life expectancy|
|Gastrointestinal and liver disease||IBD, cirrhosis, varices, GIB, ability to take antiplatelets/anticoagulation|
|Kidney disease||eGFR <30cc/min or dialysis|
|Pulmonary disease||Oxygen requirement, FEV1 <50% predicted or
|Neurological disorders||Movement disorders, dementia|
Abbreviations: BMI: body mass index; CV: cardiovascular; MMSE: mini mental state examination; MNA: mini nutritional assessment.
|Key Steps||Essential Elements||Additional Details|
|Frailty and Disability||Frailty Assessment||Gait Speed (<0.5m/sec or < 0.83 m/sec with
Frailty (Not Frail or Frail by Assessments)
|Nutritional Risk/Status||Nutritional Risk Status (BMI<21, albumin
<3.5mg/dl, >10-pound weight loss in past year,
or ≤11 on MNA)
|Physical Function||Physical function and endurance
|6-minute walk <50 m or unable to walk
Dependent in>=1 activities
|Cognitive Function||Cognitive Impairment
Depression and Prior Disabling Stroke
|MMSE <24 or dementia
Depression history or positive screen
Lag-time to benefit
|<1 year life expectancy
Survival with benefit of <25% at 2 years
- Evaluation for frailty, physical function and independence in the activities of daily living (ADL) such as, feeding, bathing, toileting and transferring).
- Evaluation should be start with screening for independence, cognition and slow walking speed (gait speed, 3 timed trials over a 5 meter distance).
- Those with gait speed over 0.83 m/s, preserved cognition and independence are likely not frail.
To assess the physical functioning, the 6 minute walk test should be done. It is possible to perform this test in outpatient setting.
The Mini Mental Status Examination (MMSE) is utilized to assess the cognitive status and scores less than 24 are considered as abnormal. Also, evaluation for depression must be done by using a validated tool such as, the Center for Epidemiologic Studies Depression Scale.
Those patients with <1 year life expectancy and who has a chance of survival with benefit of <25% at 2 years.
Survival with benefit means, survival with improvement by at least 1 New York Heart Association class in heart failure or by at least 1 Canadian Cardiovascular Society class angina symptoms, improvement in quality of life or improvement in life expectancy.
Underlying risk for SAVR is basic component to consider patient for TAVR. This risk assessment is based on several components that include:
- The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score. To calculate this score please click here.
- Main organ system dysfunction
- Procedure-specific impediments
|SAVR risk assessment|
|Risk Index||Low Risk
(Must meet ALL criteria in This column)
(Any 1 criterion in this column)
(Any 1 criterion in this column)
|Prohibitive Risk |
(Any 1 criterion in this column)
|STS PROM||<4%||4% to 8%||>8%||Predicted risk with surgery of death or major morbidity (all-cause) >50% at 1 y|
|Frailty†||None||1 Index (mild)||≥ 2 Indices (moderate to severe)||Predicted risk with surgery of death or major morbidity (all-cause) >50% at 1 y|
|Major organ system compromise
not to be improved postoperatively‡
|None||1 Organ system||No more than 2 organ systems||≥ 3 Organ systems|
|Procedure specific impediment ¶||None||Possible procedure specific impediment||Possible procedure specific impediment||Severe procedure specific impediment|
‡ Examples of major organ system compromise:
- Cardiac: severe LV systolic or diastolic dysfunction or RV dysfunction, fixed pulmonary hypertension
- CKD stage 3 or worse
- Pulmonary dysfunction with FEV1 <50% or DLCO <50% of predicted
- CNS dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, CVA with persistent physical limitation)
- GI dysfunction: Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0
- Cancer: active malignancy
- Liver: any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy.
¶ Examples: tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, or radiation damage.
|Less than stage D||Stage D|
|❑ Periodic monitoring of AS|
severity and symptoms
❑ Re-evaluate when AS severe
or symptoms occur
|Severe symptomatic AS but |
Benefit < Risk (futility)
|❑Life expectancy <1 year|
❑Chance of survival with benefit at 2 years <25%
|SAVR preferred over TAVR||TAVR preferred|
|❑Discussion with patient and family|
❑Palliative care inputs
❑Palliative balloon aortic valvuloplasty in selected patients
|❑Lower risk for surgical AVR |
❑Mechanical valve preferred
❑Other surgical considerations
❑Symptom relief or improved survival
❑Possible complications and expected recovery
❑Review of goals and expectations
|❑SAVR recommended in lower-risk patients|
❑Valve durability considerations in younger patients
❑Concurrent surgical procedure needed (e.g.aortic root replacement)
|❑Discussion with patient and family|
❑Proceed with TAVR imaging evaluation and procedure
Imaging for TAVR
General Principles and Technical Considerations
- Transthoracic Echocardiography (TTE) is the best initial imaging modality for evaluating AS severity. Although, multimodality imaging is needed for preprocedural planning and intraoperative decision making given the complex 3D anatomy of the aortic valve, sinuses, and annulus.
- Multi-Detector CT (MDCT) is a core element of the standard imaging pathway for the preprocedural planning of TAVR.
- In patients being evaluated for TAVR, MDCT systems with at least 64 detectors and a spatial resolution of 0.5 to 0.6 mm are recommended.
- Evaluation of kidney function to avoid contrast induced nephropathy must be taken in to consideration.
CV: Cardiovascular, AVR: Aortic valve replacement, AS: Aortic Stenosis, MR: Mitral Regurgitation, AR: Aortic Regurgitation, PAP: Pulmonary Artery Pressure, RV: Right Ventricle, CTA: CT angiography, PA: Pulmonary Artery, TEE: Trans Esophageal Echocardiography, TTE: Trans Thoracic Echocardiography
AVA: Aortic Valve Area; CMR: Cardiovascular Magnetic Resonance Imaging; CT: Computed Tomography; ECG: Electrocardiogram; EF: Ejection Fraction; DSE: Dobutamine Stress Echocardiography; ESRD: End-Stage Renal Disease; GFR: Glomerular Filtration Rate; LFLG: Low-Flow Low-Gradient; LV: Left Ventricular; LVEF: Left Ventricular Ejection Fraction; MAC: Mitral Annular Calcification; MDCT: Multi Detector Computed Tomography; MRA: Magnetic Resonance Angiogram;
MRI: Magnetic Resonance Imaging; MS: Mitral Stenosis; PET: Positron Emission Tomography; TAVR: Trans-catheter Aortic Valve Replacement
|TAVR Imaging Checklist|
|Region of Interest||Recommended Approach and Key
|Aortic valve morphology||TTE:
|Aortic valve function||TTE:
|LV Geometry and other
|Aortic root measurements||
|Coronary disease and
||May be considered depending on clinical
|Kidney Function Status||Recommended Approach||Key Parameters|
|Normal renal function (GFR >60) or
ESRD not expected to recover
||Aorta, great vessel, and abdominal aorta
Dissection; atheroma; stenosis; calcification
Iliac/subclavian/femoral luminal dimensions, calcification, and tortuosity
||Institutional dependent protocols
Luminal dimensions and tortuosity of peripheral vasculature
|Acute kidney injury or
ESRD with expected
||Degree of calcification and tortuosity of peripheral vasculature|
|TAVR Imaging Checklist|
|Imaging goals||Recommended Approach||Additional Details|
|Interventional planning||TAVR CTA||Predict optimal fluoroscopy angles for valve
|Confirmation of annular
|Preprocedure MDCT||Consider contrast aortic root injection if
3C TEE to confirm annular size
|Valve placement||Fluoroscopy under general anesthesia||TEE (if using general anesthesia)|
|Paravalvular leak||Direct aortic root angiography||TEE (if using general anesthesia)|
Intracardiac echocardiography (alternative)
|Evaluate valve function||TTE||Key elements of echocardiography:
|LV geometry and other
Specific CT measurements for TAVR
|TAVR CT Measurement Summary|
|Valve Size and Type|
|Region of Interest||Specific
|Aortic valve morphology
||Most useful in cases of LFLG AS where diagnosis is otherwise
unclear. May be helpful in defining number of valve cusps.
|LV geometry and other
|LV outflow tract||
||Quantification of calcification not standardized.
Large eccentric calcium may predispose for paravalvular
regurgitation and annular rupture during valve deployment.
|Annular sizing||Aortic annulus||
||Periprocedural TEE and/or balloon sizing can confirm
dimensions during case.
|Aortic root measurements||Sinus of Valsalva||
|Coronary and thoracic
||Short coronary artery height increases risk of procedure. Evaluation of coronary artery and bypass graft stenosis on select studies. Estimate risk of coronary occlusion during valve deployment.|
||Reduce procedure time and contrast load by reducing number of periprocedural root
|Vascular Access Planning|
|Vascular access||Aorta||Major/minor diameters of the following:
|Primary peripheral vasculature||Major/minor dimensions, tortuosity, calcification of the following:
|Stenosis of the following:|
and femoral head
|Distance from inferior margin of femoral
head to femoral biforcation
|TAVR Imaging Evaluation|
|Non-gated Angiogram of Chest, Abdomen and Pelvic arteries for vascular access selection||ECG gated CT of annulus and Aortic root for valve sizing selection||Left ventricles and other findings||Confirm severe Aortic Stenosis|
|Transfemoral Approach||Annular sizing||Aortic Root sizing||Additional Procedural Planning|
|Subclavian Approach||Major/Minor Dimension||Coronary Ostia height||Fluoroscopy Angulation||LVEF and LV dimension||High gradient AS|
|Apical Approach||Area||Aortic Sinus to Commissure dimension||Bypass Grafts||Estimated Pulmonary pressure||Low gradient AS|
|Other Approaches||Circumferences||Sinotubular Junction||RV to Chest wall position||Other valvular abnormalities||Reduced EF|
|Carotid||Ascending Aorta dimension||Preserved EF|
|Direct Aortic||Aortic Calcification|
Aortic Valve Morphology
- Transthoracic Echocardiography (TTE) is performed for initial visualization of aortic valve to identify the number of leaflets; size, location, extent of calcification, leaflet motion, and a preliminary view of annular size and shape.
- If additional imaging is needed, valve anatomy and function can be evaluated by cardiac magnetic resonance imaging (CMR) or ECG-gated MDCT.
Aortic Valve Function
Doppler echocardiography is superior to other imaging modalities to evaluate Aortic valve function. AS severity should be evaluated according to the ESE/ASE Recommendations for Evaluation of Valvular Stenosis and staged according to the AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease.
LV Geometry and Other Cardiac Findings
TTE also is recommended for evaluation of LV hypertrophy, chamber size, LV diastolic function, regional wall motion, and ejection fraction as well as newer measures of LV function such as global longitudinal strain. In addition, TTE is useful for assessment of aortic dilation, presence of subvalvular outflow tract obstruction, estimation of pulmonary pressures, and identification of other significant valve abnormalities.
The 3D dataset provided by MDCT are more accurate than TTE findings regarding annular size. Measurement of LV outflow tract diameter on TTE has been well validated for calculation of aortic valve area and continues to be the standard for determination of AS severity. CMR can also provide comprehensive assessment of the aortic valve, annulus, and aortic root with good correlation with MDCT. CMR can be a valuable tool in patients who cannot undergo MDCT.
Aortic Root Measurements
MDCT allows for the careful measurement of the size of the sinuses of Valsalva, the coronary ostia distance from the annulus, the size of the aorta at the sinotubular junction and 40mm above the annulus, and the extent and position of aortic calcifications.
MDCT also may be of use in identification of coronary artery and coronary bypass graft location and stenosis, evaluation of the RV to chest wall position, and identification of the aorta and LV apex to chest wall position in direct aortic approaches.
Because of high prevalence of dementia and atherosclerosis in this elderly patient population, a preprocedural work-up including carotid ultrasound and cerebrovascular MRI might be considered prior to considering or such patients for TAVR.
Because of the relatively large diameter of the delivery sheaths, appropriate vascular access imaging is critical for TAVR. It is important to evaluate the entire thoracoabdominal aorta, major thoracic arterial vasculature, carotids, and iliofemoral vasculature. MDCT is able to provide valuable dataset regarding vascular anatomy.
MDCT can assist with predicting the optimal delivery angle on fluoroscopy prior to valve deployment.
Confirmation of annular sizing
Preprocedural MDCT is the best modality to evaluate annular size. At the time of the procedure, fluoroscopy is the main imaging modality. If questions remain about the correct annular sizing, balloon inflation with contrast root injection can be performed. Also, 3D TEE is able to evaluate the annular size, at the time of the procedure.
Optimal deployment angles are obtained using fluoroscopy and root injections. Deployment is done under fluoroscopy at many institutions, although TEE is an alternative approach.
TEE and TTE are required to assess the valve in different aspects. Also, TEE can be used to assess the immediate gradient changes after valve seating. Aortic root angiography also may be used to assess for regurgitation after valve implantation. As the volume of cases performed without general anesthesia increases, there may be an expanding role for periprocedural TTE.
Immediate complications such as annular rupture resulting in pericardial effusion and tamponade can be detected by TEE, TTE, angiography, and direct hemodynamic measurements.
Long-Term Postprocedural Evaluation
Evaluate Valve Function
- Echocardiography is recommended to evaluate the valve postprocedurally to search for valvular and paravalvular leak, valve migration, complications such as annular or sinus rupture, valve thrombosis, endocarditis, paravalvular abscess, LV size, function and remodeling, and pulmonary pressures.
- MDCT can be used to evaluate valve anatomy A and to evaluate for valve thrombosis.
- CMR can also be used to quantify AR and can be complementary to TTE for the quantification of paravalvular leak.
LV Geometry and Other Cardiac Findings
TTE is used to evaluate changes in LV function after TAVR.
The following table describes the TAVR procedure checklist. Abbreviations: AR: aortic regurgitation; AVR: aortic valve replacement; BAV: balloon aortic valvuloplasty; PA: pulmonary artery; TEE: transesophageal echocardiography
|Checklist for TAVR Procedure|
|Key Steps||Essential Elements||Additional Details|
|Preplanning by Heart Team|
||Suitability of access – careful reconstructions|
|Location of procedure||
||Need for intraoperative TEE impacts anesthesia type|
|Anticipated complication management||
|Vascular access and closure||
||Assess AR immediately post-BAV as well as need for hemodynamic support|
|Valve delivery and
|Post-deployment valve assessments||
||Immediate assessment with echo,hemodynamics, aortogram postimplant|
|Other complication assessment and management||
- The Heart Valve Team must decide and plan for valve selection, access choice and location of procedure.
Valve selection is dependent on 2 major factors,
- Which type of valve should be considered (balloon expandable or self expanding) based on anatomical reasons
- Available valve sizes.
There currently are 2 TAVR valves commercially available in the United States:
- The balloon-expandable Sapien family of transcatheter heart valves (Edwards Lifesciences) made of bovine pericardium mounted in a cylindrical, relatively short cobaltchromium stent.
- The self-expanding CoreValve (Medtronic) family of transcatheter heart valves, which are made of porcine pericardium mounted in a taller, nitinol stent with an adaptive shape and supra-annular design.
Randomized clinical trials showed similar 1-year mortality, strokes, and re-admissions due to heart failure with either valve.
Important factors that must be considered in valve selection:
- Annulus dimensions and geometry
- Native valve and aortic root/LV outflow tract anatomy
- Coronary height
- Amount and distribution of calcification
Self expanding valves are preferred over balloon expandable in the following circumstances:
- Patients with heavy calcification of the aortic annulus/LV outflow tract with an attendant risk of rupture
- Extremely oval-shaped annulus or for transfemoral access when femoral artery diameter is between 5.0 and 5.5 mm.
Balloon expanding valves are preferred over self expandable in this situations:
- Dilated ascending (>43 mm) aorta
- Severely angulated aorta (aortoventricular angle >70 degrees, particularly for transfemoral access).
- A balloon-expandable valve is the only option in patients needing a transapical approach (e.g., those with a significant aortic calcification and peripheral vascular disease).
Several other valve designs and platforms are currently under investigation, and valve teams of the future will need to have a sound understanding of their relative merits and disadvantages for treating specific subsets of patients with AS.
The patient’s atherosclerotic load and location, arterial size and tortuosity, and presence of mural thrombus are important factors in access selection.
When possible, transfemoral access is the preferred TAVR delivery route.
Location of the Procedure
Optimal equipment requirements include a state of the art, large field of view fluoroscopic imaging system with a fixed overhead or floor mounted system that has positioning capability rather than a portable C-arm system. other equipment that are required in the TAVR center include: 3D echocardiography, MDCT, CMR, full catheterization laboratory hemodynamic capability, cardiopulmonary bypass machines and related ancillary supplies, with an inventory of interventional cardiology equipment for balloon aortic valvuloplasty, coronary balloons, stents, and 0.014-inch wires if coronary occlusion occurs as a complication of device deployment.
The procedure location should also be fully capable of providing anesthesia services, including advanced airway management, general anesthesia, full hemodynamic monitoring, and administration of vasoactive agents into the central circulation.
In addition to the interventional cardiologist, cardiothoracic surgeon, and cardiovascular anesthesiologist, other personnel required during the TAVR procedure include a cardiovascular imaging specialist, cardiac perfusionists, and other personnel trained in hemodynamic monitoring and able to rapidly deal with procedural complications.
Procedural complications, including hemodynamic collapse are common among patients undergoing TAVR. Preventing prolonged hypotension is a key goal during this procedure. Predictive factors for higher risk patients for intraprocedural instability include:
Depressed EF, elevated pulmonary pressures, significant mitral or tricuspid regurgitation, incomplete revascularization, collateral-dependent coronary and cerebral circulation, chronic lung disease, heart failure, and acute/chronic kidney disease.
TAVR is evolving from a procedure done routinely under general anesthesia with invasive central monitoring, a pulmonary artery catheter and transesophageal echocardiography to one that can safely be performed with conscious sedation and minimal instrumentation. Recent surveys showed better outcomes with conscious sedation than general anesthesia. Now, it is recommended that TAVR procedures under conscious sedation should be performed in highly experienced centers, and not as an initial starting strategy for a TAVR program, and only using the transfemoral approach.
Conscious sedation is best avoided in patients requiring TEE guidance during valve deployment and in those with borderline vascular access, cognitive or language barriers, an inability to stay still or lie flat, chronic pain, morbid obesity, or other issues.
Anticipated complication management
The following table summarizes the common complication for TAVR procedure and their treatment options.
Abbreviations: AVR: aortic valve replacement; CABG: coronary artery bypass grafting; CPB: cardiopulmonary bypass; CVA: cerebrovascular accident; PCI: percutaneous coronary intervention; PPM: permanent pacemaker; SAVR: surgical aortic valve replacement; TAVR: transcatheter aortic valve replacement
|TAVR Procedural Complications and Management|
|Central valvular aortic regurgitation||
|Paravalvular aortic regurgitation||
|Shock or hemodynamic collapse||
|Complete heart block||Transvenous pacing with conversion to PPM if needed|
|Access site-related complications||Urgent endovascular or surgical repair|
Typically, a temporary transvenous lead is passed through the femoral or internal jugular veins or, in the case of transapical procedures, can also be sewn directly on the epicardial surface. Arterial pressure monitoring may be done via the radial artery. At least 1 large-volume line is obtained peripherally or centrally. Immediate access to a defibrillator device
is necessary because ventricular fibrillation can occur with manipulation of catheters within the heart or with rapid ventricular pacing. Volume status needs to be supplemented carefully to prevent volume overload and hypovolemia. Inhaled nitric oxide or inhaled epoprostenol should be readily available for the treatment of severe pulmonary hypertension and right ventricular failure.
Routine surgical antibiotic prophylaxis administered prior to surgical incision or vascular access is warranted to decrease the risk of wound infection and endocarditis.
Vascular ultrasound may be needed to assess vessel wall calcification prior to puncture.
- For transfemoral access, both percutaneous and cutdown access approaches are used. Percutaneous approaches are preferred when access sites are relatively large and free of significant atherosclerotic disease and calcification, and in patients with wound healing concerns.
- For transapical cases, access is obtained via a left anterior thoracotomy, which is made after localization of the apex by fluoroscopy, TTE, and/or TEE.
- For transaortic cases, access is either through an upper partial sternotomy or a minthoracotomy at the second or third right intercostal space.
One of the key steps in preimplant is identifying the optimal fluoroscopic and intraprocedural views for device deployment. A pigtail catheter is typically placed in the noncoronary cusp (for self-expanding valves) and right coronary cusp (for balloon-expandable valves) and aortography is performed in a fluoroscopic view perpendicular to the native valve in order to identify the coplanar or coaxial view.
Anticoagulation therapy is usually initiated after insertion of the large sheath into the vasculature, and repeated to maintain an activated clotting time (ACT) of >250–300 seconds.
Following this, the aortic valve is crossed using standard interventional techniques and a stiff wire exchange is performed, with redundancy in the LV cavity to prevent loss of position. Prior to passage of the valve, predilation of the annulus may be required. Standard techniques of percutaneous balloon aortic valvuloplasty are employed, with rapid pacing during inflation. Radiographic contrast opacification of the root during maximal inflation may provide useful information when the location of the coronary ostia in relation to the annulus and the leaflet calcification or any other aortic root pathology requires further delineation.
This is also helpful in situations where valve sizing falls between valve sizes. For example, use a 22-mm or 23-mm Edwards balloon when deciding between a 23-mm and a 26-mm transcatheter valve. If the 22-mm or 23-mm balloon reaches the hinge points and there is no significant leak around the balloon on angiography, then generally the 23-mm transcatheter valve would be selected. If the 22-mm balloon does not reach the hinge points and/or there is clear leak into the ventricle around the balloon, then the 26-mm valve would generally be implanted.
Valve Delivery and Deployment
The transcatheter valve is positioned across the annulus in the predetermined coaxial annular plane. The optimal landing zone should be identified and will vary depending on the type of valve.
Post-deployment Valve Assessments
Immediately following implantation, valve position and location should be checked with echocardiography (TTE or TEE), hemodynamics, and/or aortography. A quick assessment for changes in MV or LV function and new pericardial effusion should also be routinely performed.
Post-TAVR AR must be characterized in terms of its location, severity, and cause and should integrate both central and paravalvular origins to allow for an estimate of overall volumetric impact.
Central regurgitation is generally a result of improper valve deployment or sizing. Paravalvular regurgitation is generally caused by underdeployment of the prosthesis, very low implants (e.g., below the valve skirt of the self-expanding valve), or calcific deposits, which prevent the valve unit from properly seating and sealing within the annulus. Acute leaks may respond to repeat ballooning of the valve to obtain a better seal and greater expansion of the valve.
Following TAVR deployment, the delivery system and sheath are removed. Anticoagulation is typically reversed and access site closure is performed.
Post-TAVR Clinical Management
The long-term management of patients after TAVR is similar to that of patients after SAVR. The major differences are that patients undergoing TAVR tend to be older and have more comorbid
conditions; an access site replaces the surgical incision; and the long-term durability of transcatheter valves is not yet known.
Basic principles for management of patients after valve replacement include:
- Periodic monitoring of prosthetic valve function
- Management of comorbid conditions
- Monitoring for cardiac conduction defects and heart block
- Promotion of a healthy lifestyle with cardiac risk factor reduction
- Antithrombotic therapy as appropriate
- Optimal dental hygiene and endocarditis prophylaxis
- Patient education and coordination of care
- Cardiac rehabilitation and promotion of physical activity as appropriate.
The following table describes Checklist for Post-TAVR Clinical Management.
Abbreviations: ACC:American College of Cardiology; ADLs: activities of daily living; AF: atrial fibrillation; AHA: American Heart Association; AR: aortic regurgitation; ASA: aspirin; ECG: electrocardiogram; GI: gastrointestinal; LV: left ventricular; MD: medical doctor; NOAC: new oral anticoagulant; OT: occupational therapy; PA: pulmonary artery; PT: physical therapy; TAVR: transcatheter aortic valve replacement; VTE: venous thromboembolism.
|Checklist for Post-TAVR Clinical Management|
|Key Steps||Essential Elements||Additional Details|
|Immediate Postprocedure Management|
|Waking from sedation||
||Encourage physical activity|
|Concurrent cardiac disease||
|Monitor for post-TAVR
|Dental hygiene and
Immediate Postprocedure Management
After TAVR procedure, patients should be monitored for recovery from sedation and anesthesia.
Waking from sedation
When general anesthesia is used, early extubation is encouraged, as for any general anesthesia procedure.
Monitoring for mental status, telemetry, vital signs, volume status, postprocedure blood testing and access site for adequate hemostasis is required for either conscious sedation or general anesthesia.
Appropriate pain management, continued mental status monitoring, and early mobilization are especially important post-TAVR as patients often are elderly with a high burden of comorbidities.
Discharge plan should be prepared before the procedure and should include physical and occupational therapy.
Early discharge (within 72 hours) does not increase the risk of 30-day mortality, bleeding, pacer implantation or re-hospitalization in selected patients undergoing transfemoral TAVR.
Long Term Follow up
Integration and coordination of medical care is essential post-TAVR to ensure optimal patient outcomes. Outcomes after TAVR depend strongly on overall patient health and clinical conditions other than the aortic valve disease.
Readmission rates are over 40% in the first year after the procedure, most often due to non-cardiac causes (60% of re-admissions); common readmission diagnoses include respiratory problems, infections and bleeding events. Cardiac re-admissions are most often for arrhythmias or heart failure.
Mortality rates after TAVR remain very high, with about 30% of patients dying within 3 years of the procedure. Non-cardiac causes of death predominate after the first 6 months. These data emphasize the need for integrated non-cardiac and cardiac care in these patients, including end-of-life planning.
The Heart Valve Team is responsible for care for the first 30 days because procedural complications are most likely in this time interval. After 30 days, there should be a formal transfer of care from the Heart Valve Team back to the referring primary cardiologist. In stable patients with no complications and few co-morbidities, the primary cardiologist should see the patient at 6 months and then annually, and more frequently as needed for complications or concurrent medical conditions. The primary care provider and cardiologist should communicate frequently to ensure coordination of care, with clear patient instructions on when and how to contact the care team.
The current standard antithrombotic therapy after TAVR is clopidogrel 75 mg orally daily for 3–6 months with oral aspirin 75–100 mg daily lifelong. Patients with chronic AF or other indications for long-term anticoagulation should receive anticoagulation as per guidelines for AF in patients with prosthetic heart valves. Vitamin-K antagonist therapy may be considered in the first 3 months after TAVR in patients at risk of AF or valve thrombosis, depending on the specific risk-benefit ratio in that patient. When vitamin-K antagonist therapy is used, continuation of aspirin is reasonable, but it may be prudent to avoid other antiplatelet therapy in some patients given the increased risk of bleeding with multiple simultaneous antithrombotic agents.
Concurrent Cardiac Disease
Long-term management focuses on treatment of comorbid cardiac and non-cardiac conditions.
|Coronary artery disease||Renal disease|
|MV disease||Cognitive impairment|
non-cardiac conditions are best managed by the primary care provider or geriatrician, with the cardiologist providing consultation regarding any changes in cardiac signs or symptoms. Referral back to the Heart Valve Team is appropriate when prosthetic valve dysfunction is a concern or if a second interventional procedure might be needed for another valve or for coronary artery disease. In addition to echocardiography, periodic ECG monitoring is recommended for detection of asymptomatic AF and because heart block or other conduction defects can occur late after TAVR.
Monitor for Post-TAVR Complications
Echocardiography before discharge provides a new baseline study of transcatheter valve function and should include:
the antegrade TAVR velocity, mean transaortic gradient, valve area, assessment of paravalvular AR, LV size, regional wall motion and ejection fraction, evaluation of MV anatomy and function, estimation of pulmonary pressures and evaluation of the right ventricle.
Repeat echocardiography is recommended at 30 days and then at least annually.
Routine ECG assessment is also recommended owing to a potential need for pacemaker implantation beyond the initial 30-day period, particularly following implantation of the self expanding TAVR.
The TAVR procedure is associated with a high risk of dislodgement of microdebris from arch atheroma or from the valve itself with subsequent embolic stroke. Clinical cerebrovascular event rates are around 3%–5% at 30 days.
Dental Hygiene and Antibiotic Prophylaxis
A TAVR is a risk factor for endocarditis, with reported rates of early prosthetic valve endocarditis ranging from 0.3% to 3.4 % per patient-year.
Standard antibiotic prophylaxis after TAVR is the same as for all prosthetic valves per ACC Guidelines. In addition, patients should be encouraged to use optimal dental hygiene and see a dentist regularly for routine cleaning and dental care, with antibiotic prophylaxis at each visit.
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- ↑ 5.0 5.1 Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quiñones M (2009). "Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice". J Am Soc Echocardiogr. 22 (1): 1–23, quiz 101–2. doi:10.1016/j.echo.2008.11.029. PMID 19130998.
- ↑ Hahn RT (2016). "Transcathether Valve Replacement and Valve Repair: Review of Procedures and Intraprocedural Echocardiographic Imaging". Circ. Res. 119 (2): 341–56. doi:10.1161/CIRCRESAHA.116.307972. PMID 27390336.
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- ↑ Pibarot P, Hahn RT, Weissman NJ, Monaghan MJ (2015). "Assessment of paravalvular regurgitation following TAVR: a proposal of unifying grading scheme". JACC Cardiovasc Imaging. 8 (3): 340–60. doi:10.1016/j.jcmg.2015.01.008. PMID 25772838.
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- ↑ Beohar N, Zajarias A, Thourani VH, Herrmann HC, Mack M, Kapadia S, Green P, Arnold SV, Cohen DJ, Généreux P, Xu K, Leon MB, Kirtane AJ (2014). "Analysis of early out-of hospital mortality after transcatheter aortic valve implantation among patients with aortic stenosis successfully discharged from the hospital and alive at 30 days (from the placement of aortic transcatheter valves trial)". Am. J. Cardiol. 114 (10): 1550–5. doi:10.1016/j.amjcard.2014.08.021. PMC 4482466. PMID 25277334.
- ↑ Durand E, Eltchaninoff H, Canville A, Bouhzam N, Godin M, Tron C, Rodriguez C, Litzler PY, Bauer F, Cribier A (2015). "Feasibility and safety of early discharge after transfemoral transcatheter aortic valve implantation with the Edwards SAPIEN-XT prosthesis". Am. J. Cardiol. 115 (8): 1116–22. doi:10.1016/j.amjcard.2015.01.546. PMID 25726383.
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- ↑ Mack MJ, Leon MB, Smith CR, Miller DC, Moses JW, Tuzcu EM, Webb JG, Douglas PS, Anderson WN, Blackstone EH, Kodali SK, Makkar RR, Fontana GP, Kapadia S, Bavaria J, Hahn RT, Thourani VH, Babaliaros V, Pichard A, Herrmann HC, Brown DL, Williams M, Akin J, Davidson MJ, Svensson LG (2015). "5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial". Lancet. 385 (9986): 2477–84. doi:10.1016/S0140-6736(15)60308-7. PMID 25788234.
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- ↑ Latib A, Naim C, De Bonis M, Sinning JM, Maisano F, Barbanti M, Parolari A, Lorusso R, Testa L, Actis Dato GM, Miceli A, Sponga S, Rosato F, De Vincentiis C, Werner N, Fiorina C, Bartorelli A, Di Gregorio O, Casilli F, Muratori M, Alamanni F, Glauber M, Livi U, Nickenig G, Tamburino C, Alfieri O, Colombo A (2014). "TAVR-associated prosthetic valve infective endocarditis: results of a large, multicenter registry". J. Am. Coll. Cardiol. 64 (20): 2176–8. doi:10.1016/j.jacc.2014.09.021. PMID 25457406.
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