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Cardiology
Transcatheter Aortic Valve Implantation
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
9 sections · 133 slides
Aortic stenosis and the case for a transcatheter valve
- Scope of this topic
- Burden of severe aortic stenosis
- Risk factors for aortic stenosis
- Etiological classification of aortic stenosis
- Stenotic aortic valve, gross specimen
- Pathogenesis of degenerative aortic stenosis
- Calcific valve tissue on histology
- From surgical replacement to transcatheter therapy
- Definition of severe aortic stenosis
Aortic root anatomy and preprocedural imaging
- Aortic root complex
- Why the aortic root must be mapped before TAVR
- Coronary ostia and the aortic cusps
- Prosthesis-patient mismatch
- Annular and outflow tract calcification
- Preoperative imaging modalities
- Value of annular sizing
Vascular access and the transfemoral procedure
- Transfemoral access
- Contraindications to the transfemoral route
- Alternative access routes
- Transcarotid access
- Screening before transcarotid access
- Transaxillary, transcaval and transapical access
- Rapid ventricular pacing
- Sequence of the transfemoral procedure
- Obtaining access and placing the pigtail
- Large-bore access and closure strategy
- Crossing the stenotic valve
- Fluoroscopic view and balloon valvuloplasty
- Deployment technique by valve type
- Balloon-expandable valve at the aortic annulus
- Assessment after valve deployment
- Managing access-site complications
- Self-expanding valve deployment on fluoroscopy
Patient selection, risk assessment and guidelines
- The multidisciplinary heart team
- Components of risk assessment
- Limitations of surgical risk scores
- Timing of intervention in aortic stenosis
- Indications for aortic valve replacement
- Choosing TAVR over surgical replacement
- Guideline pathway for TAVR versus SAVR
- Age thresholds in current guidelines
Transcatheter valve platforms
- The two dominant valve platforms
- Edwards Sapien valve design
- Indications and cautions for balloon-expandable valves
- Sapien and Sapien XT
- Sapien 3 and Sapien 3 Ultra
- Take-home from the Sapien comparison table
- Characteristics of the Edwards Sapien Valves
- Medtronic CoreValve platform design
- Evolut R
- Evolut Pro, Pro+ and FX series
- Evolut Low Risk Trial and platform positioning
- Take-home from the Evolut comparison table
- Comparison of Medtronic CoreValve Evolut Series
- Abbott transcatheter aortic valves
- Portico with FlexNav system
- Navitor system
Landmark trials across the surgical risk spectrum
- PARTNER cohort B: inoperable patients
- PARTNER cohort B: longer-term results
- PARTNER A: high surgical risk
- Complication profiles: TAVR versus surgery
- CoreValve US pivotal trial
- Intermediate-risk patients: background
- SURTAVI and PARTNER II cohort A
- PARTNER II cohort A: secondary outcomes
- PARTNER 3: low surgical risk
- Limitations of PARTNER 3
- NOTION trial
- NOTION trial: advantages of surgery
- Asymptomatic severe aortic stenosis
- EARLY TAVR results
Complications and durability
- Complications of TAVR
- Paravalvular leak: mechanism
- Paravalvular leak: incidence and consequences
- Conduction abnormalities after TAVR
- Reducing pacemaker rates
- Stroke after TAVR
- Cerebral embolic protection devices
- Vascular complications
- Coronary obstruction: incidence and outcome
- Anatomical predictors of coronary obstruction
- Preventing and managing coronary obstruction
- Coronary obstruction in valve-in-valve procedures
- Structural valve deterioration: the durability question
- Evidence on durability
- Standardised definitions of valve deterioration
- Classification of Structural Valve Deterioration
- Valve-in-valve TAVR for failed bioprostheses
- Valve-in-valve versus redo surgery
- TAVR explantation
- Lifetime valve management
Special anatomical and clinical situations
- Bicuspid aortic valve: the problem
- Bicuspid aortic valve: current evidence
- When surgery is preferred in bicuspid disease
- Prosthesis-patient mismatch in small annuli
- Valve choice in the small annulus
- Clinical impact of mismatch after TAVR
- Pure aortic regurgitation: why it is difficult
- Technique for TAVR in pure aortic regurgitation
- Current position on TAVR for pure regurgitation
- Reduced ejection fraction
- Prognosis and guidance in low ejection fraction
- Coronary artery disease with aortic stenosis
- Timing of revascularisation and valve choice
- Mitral and tricuspid regurgitation
- Infective endocarditis and TAVR
Summary and references
- Key points on patient selection
- Key points on devices and complications
- Conclusions
- References
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- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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