Transcatheter aortic valve replacement: 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 is the mainstay of treatment of symptomatic aortic stenosis (AS). In properly selected patients, surgical aortic valve replacement offers substantial improvements in symptoms and life expectancy. However, aortic valve surgery entails substantial risks for some patients with severe comorbidities, and for some considered at "extreme" risk, surgery is not appropriate. In others, technical limitations, eg, porcelain aorta (extensively calcified ascending aorta and/or aortic arch), may mean that surgery is not feasible. Percutaneous aortic balloon valvotomy was developed as a less invasive means to treat AS but has important limitations. Subsequently developed catheter-based techniques for aortic valve implantation have become established as the standard of care for treating AS in patients with unacceptably high estimated surgical risks, and can be considered a realistic alternative in those considered high risk. A multidisciplinary team approach is recommended in approaching patients with symptomatic AS.
This topic will review periprocedural management of transcatheter aortic valve implantation, which has been termed "transcatheter aortic valve replacement" . 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 replacement (TAVR) should be fully evaluated for symptoms, severity of their aortic stenosis and comorbid pathologies. The indication for valve replacement 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 "Transcatheter aortic valve replacement: Indications and outcomes".)
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 TAVR candidates. Preprocedural imaging is discussed in detail separately. (See "Imaging for transcatheter aortic valve replacement", section on 'Preprocedural assessment' and "Low flow, low gradient severe aortic stenosis", section on 'Differentiating true stenosis from pseudostenosis'.)
General management and monitoring — Routine antibiotic prophylaxis is recommended for all patients undergoing transcatheter aortic valve replacement (TAVR) prior to surgical incision or vascular access to reduce the risk of wound infection and endocarditis .
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- 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