Transcatheter aortic valve implantation: Periprocedural management
- Stephen JD Brecker, MD, FRCP, FESC, FACC
Stephen JD Brecker, MD, FRCP, FESC, FACC
- Section Editor — Valvular and Aortic Disease
- Chief of Cardiology
- Clinical Academic Group
- St. George's Hospital & University of London
- Section Editors
- Jeroen J Bax, MD, PhD
Jeroen J Bax, MD, PhD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Cardiology
- Leiden University Medical Center, The Netherlands
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
Aortic valve replacement (AVR) has been the mainstay of treatment of symptomatic severe aortic stenosis (AS). The role of transcatheter aortic valve implantation (TAVI; also known as transcatheter aortic valve replacement or TAVR) as an alternative to surgical aortic valve replacement (SAVR) is evolving. A multidisciplinary team approach is recommended in approaching patients with symptomatic AS.
This topic will review periprocedural management of TAVI . Indications for aortic valve replacement, surgical aortic valve replacement, estimating the risk of aortic valve surgery, medical therapy of symptomatic AS, and percutaneous aortic valvuloplasty are discussed separately. (See "Indications for valve replacement in aortic stenosis in adults" and "Choice of prosthetic heart valve for surgical replacement" and "Estimating the mortality risk of valvular surgery" and "Medical management of symptomatic aortic stenosis" and "Percutaneous balloon aortic valvotomy".)
Candidates for transcatheter aortic valve implantation (TAVI) should be fully evaluated for symptoms, severity of their aortic stenosis and comorbid pathologies. The indication for valve intervention (SAVR or TAVI) and choice of therapy based upon potential risks and benefits of treatment options should be discussed at a multidisciplinary heart team meeting. This should comprise interventional and noninterventional cardiologists, cardiac surgeons, imaging cardiologists, and possibly critical care/respiratory physicians, etc. Potential risk factors such as depressed left ventricular ejection fraction, coronary artery disease, kidney disease , and prior stroke and pulmonary disease should be considered. Potential access issues and likely delivery approach should be discussed since this may impact the risk-benefit analysis of treatment options. (See "Indications for valve replacement in aortic stenosis in adults" and "Choice of therapy for symptomatic severe aortic stenosis".)
Preprocedural testing should include routine blood tests (including complete blood count, prothrombin time, activated partial thromboplastin time, electrolytes, blood urea nitrogen, and serum creatinine), electrocardiogram, echocardiography (and may require stress echocardiography if low gradient aortic stenosis is being assessed), and coronary angiography. Comprehensive computed tomography angiography to assess aortic annulus geometry and peripheral access is now considered the standard of care in assessing TAVI candidates. Preprocedural imaging is discussed in detail separately. (See "Imaging for transcatheter aortic valve implantation", section on 'Preprocedural assessment' and "Clinical manifestations and diagnosis of low gradient severe aortic stenosis", section on 'Diagnosis and evaluation'.)
General management and monitoring — Routine antibiotic prophylaxis is recommended for all patients undergoing transcatheter aortic valve implantation (TAVI) prior to surgical incision or vascular access to reduce the risk of wound infection and endocarditis .
- Clegg SD, Krantz MJ. Transcatheter aortic valve replacement: what's in a name? J Am Coll Cardiol 2012; 60:239.
- Holmes DR Jr, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol 2012; 59:1200.
- Brecker SJ, Bleiziffer S, Bosmans J, et al. Impact of Anesthesia Type on Outcomes of Transcatheter Aortic Valve Implantation (from the Multicenter ADVANCE Study). Am J Cardiol 2016; 117:1332.
- Cribier A, Eltchaninoff H, Tron C, et al. Treatment of calcific aortic stenosis with the percutaneous heart valve: mid-term follow-up from the initial feasibility studies: the French experience. J Am Coll Cardiol 2006; 47:1214.
- Zajarias A, Cribier AG. Outcomes and safety of percutaneous aortic valve replacement. J Am Coll Cardiol 2009; 53:1829.
- Leon MB, Smith CR, Mack MJ, et al. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med 2016; 374:1609.
- Petronio AS, De Carlo M, Bedogni F, et al. Safety and efficacy of the subclavian approach for transcatheter aortic valve implantation with the CoreValve revalving system. Circ Cardiovasc Interv 2010; 3:359.
- Lardizabal JA, O'Neill BP, Desai HV, et al. The transaortic approach for transcatheter aortic valve replacement: initial clinical experience in the United States. J Am Coll Cardiol 2013; 61:2341.
- Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010; 363:1597.
- Makkar RR, Fontana GP, Jilaihawi H, et al. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med 2012; 366:1696.
- http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cftopic/pma/pma.cfm?num=p100041 (Accessed on March 12, 2014).
- PREPROCEDURAL CONSIDERATIONS
- PROCEDURAL CONSIDERATIONS
- General management and monitoring
- Delivery techniques
- - Percutaneous retrograde approach
- - Transaortic surgical retrograde approach
- - Transapical antegrade approach
- Implantation technique
- POST-PROCEDURAL CARE
- Antithrombotic therapy
- Prophylaxis for bacterial endocarditis
- SUMMARY AND RECOMMENDATIONS