From the Guidelines
The workup for aortic valve replacement involves a comprehensive evaluation, including clinical assessment, transthoracic echocardiography, and advanced imaging like CT angiography, to determine the need for surgery and assess surgical risk, as recommended by the most recent guidelines 1. The evaluation process starts with a thorough clinical assessment, including medical history and physical examination, to evaluate symptoms like chest pain, shortness of breath, syncope, or heart failure.
- Transthoracic echocardiography is the cornerstone diagnostic test, providing information about valve morphology, stenosis or regurgitation severity, left ventricular function, and other cardiac abnormalities.
- Transesophageal echocardiography may be performed for better visualization if transthoracic images are suboptimal.
- Cardiac catheterization is often conducted to assess coronary artery disease, which frequently coexists with aortic valve disease and may require concurrent coronary artery bypass grafting.
- Laboratory tests include complete blood count, comprehensive metabolic panel, coagulation studies, and cardiac biomarkers.
- Chest X-ray and electrocardiogram help evaluate cardiac size and rhythm abnormalities.
- Advanced imaging like CT angiography may be performed, particularly when considering transcatheter aortic valve replacement (TAVR), to assess aortic anatomy and vascular access routes, as outlined in the 2023 update of the ACR Appropriateness Criteria for preprocedural planning for TAVR 1.
- Pulmonary function tests and carotid ultrasound may be included to evaluate operative risk.
- Dental evaluation is necessary to identify and treat potential sources of infection before valve surgery. This comprehensive workup ensures appropriate patient selection, optimal timing of intervention, and helps determine whether surgical (SAVR) or transcatheter (TAVR) approach is most suitable for each individual patient, with the goal of minimizing morbidity, mortality, and improving quality of life, as emphasized in the 2017 ACC Expert Consensus Decision Pathway for TAVR 1.
From the Research
Workup for Aortic Valve Replacement
The workup for aortic valve replacement involves several diagnostic tests and evaluations to determine the best course of treatment for patients with aortic valve disease. Some of the key components of the workup include:
- Coronary angiography to evaluate the presence and severity of coronary artery disease (CAD) 2
- Computed tomography (CT) angiography to assess the aortic root, evaluate the iliofemoral access route, and predict appropriate projection angles for prosthesis deployment 3, 4
- Echocardiography to evaluate the aortic valve anatomy and geometry, as well as to assess left ventricular function
- Multimodality imaging techniques, such as CT and echocardiography, to reinforce the rationale for intervening early and mitigating the risk of ongoing progression to advanced heart failure 5
Pre-Procedural Evaluation
The pre-procedural evaluation for transcatheter aortic valve replacement (TAVR) is critical to ensure that patients are properly selected and prepared for the procedure. This evaluation includes:
- Assessment of the aortic annulus anatomy and geometry using CT angiography to support appropriate patient selection and prosthesis sizing 3
- Evaluation of the iliofemoral access route to predict potential vascular access complications 3, 4
- Identification of significant coronary lesions that may require percutaneous revascularization before TAVR 2, 6
Post-Procedural Evaluation
After TAVR, patients require ongoing evaluation and management to ensure optimal outcomes. This includes:
- Postprocedural CT imaging to document procedural success, evaluate prosthesis positioning, and identify asymptomatic complications 3
- Coronary angiography and percutaneous coronary intervention as needed to manage coronary events post-TAVR 6
- Ongoing monitoring and management of heart failure, as concomitant aortic stenosis in heart failure is associated with high rates of mortality and morbidity 5