What are the indications for transcatheter aortic valve replacement (TAVR)?

Indications for TAVR

TAVR is recommended for patients with severe, symptomatic, calcific stenosis of a trileaflet aortic valve who have prohibitive surgical risk (≥50% mortality or irreversible morbidity at 30 days), and is a reasonable alternative to surgical AVR in high-risk patients (STS score ≥8%). 1

Primary Indications

Prohibitive Surgical Risk (Class I Recommendation)

TAVR is the preferred treatment when patients meet ALL of the following criteria 1:

• Severe AS defined as:

  • Aortic jet velocity ≥4.0 m/s, OR
  • Aortic valve area (AVA) ≤1.0 cm², OR
  • AV index ≤0.6 cm²/m², OR
  • Mean gradient ≥40 mm Hg
  • Severely reduced, calcified leaflet motion

• Symptomatic disease (dyspnea, angina, syncope, or heart failure)

• Prohibitive surgical risk defined as:

  • Estimated ≥50% risk of mortality or irreversible morbidity at 30 days (assessed by one cardiologist and 2 cardiothoracic surgeons), OR
  • Other prohibitive factors: frailty, prior radiation therapy, porcelain aorta, severe hepatic or pulmonary disease

• Suitable anatomy:

  • Aortic annulus size appropriate for available TAVR devices
  • Valve plane to coronary ostium height adequate
  • Adequate vascular access (femoral, iliac, subclavian, axillary) OR suitability for apical approach

• Predicted survival >12 months

High Surgical Risk (Class IIa Recommendation)

TAVR is a reasonable alternative to surgical AVR when 1:

• All criteria above are met EXCEPT
• STS score ≥8% (originally ≥10% in PARTNER trial, modified to ≥8%)
• Documented by 2 surgeons that true predicted mortality is ≥15%

Expanded Indications (2020 Guidelines)

The 2021 ACC/AHA guidelines expanded TAVR indications to include 2:

• Age ≥70 years with suitable anatomy across all risk categories when transfemoral approach is feasible
• LVEF <50% with severe AS (same considerations as symptomatic patients)
• Preference for transfemoral TAVI over surgical AVR in patients >80 years due to valve durability likely exceeding life expectancy

Contraindications and Situations Where TAVR is NOT Currently Recommended

TAVR should NOT be performed in 1:

• Acceptable/low surgical risk in patients <70 years (insufficient data)
• Bicuspid aortic valve (limited data, though evolving)
• Failing bioprosthetic aortic valve (valve-in-valve procedures require specific consideration)
• Severe mitral annular calcification or severe MR
• Moderate AS (not severe)
• Severe aortic regurgitation without stenosis
• Subaortic stenosis
• Unsuitable anatomy (annulus too small/large, inadequate vascular access)

Critical Anatomical Requirements

Severe AS in Low-Flow States

In patients with LV systolic dysfunction, severe AS diagnosis requires 1:

• Calcified leaflets with reduced systolic motion, AND
• Dobutamine stress echo showing:
  • Aortic velocity ≥4.0 m/s OR mean gradient ≥40 mm Hg
  • Valve area ≤1.0 cm² OR AV index ≤0.6 cm²/m² at any flow rate

Essential Pre-TAVR Evaluation

Every patient requires 1:

• Risk stratification: STS score calculation
• Comorbidity assessment: Pulmonary function tests (if COPD), malignancy staging, cognitive assessment
• Imaging confirmation:
  • Severity of AS and associated CAD
  • LV function
  • Associated valvular disease
  • Cerebrovascular disease extent
• Procedural planning imaging:
  • Annular sizing for device selection
  • Detailed arterial anatomy (peripheral aortoiliac, aortic arch, ascending aorta)

Team-Based Approach Requirement

TAVR mandates a multidisciplinary heart team including 1:

• Primary cardiologist
• Cardiovascular surgeon
• Interventional cardiologist
• Cardiac anesthesiologist
• Heart failure specialist
• Imaging specialists
• Nursing care team
• Patient and family as active participants

Common Pitfalls to Avoid

1. Do not perform TAVR without surgical backup available onsite - this is a foundational requirement 1

2. Do not rely solely on STS score - prohibitive risk includes qualitative factors (frailty, porcelain aorta, radiation) that scores miss 1

3. Transfemoral access is critical - mortality is higher with non-femoral approaches; when transfemoral is not feasible, strongly reconsider surgical AVR or palliative care 2

4. Do not assume TAVR is appropriate for bicuspid valves - this remains investigational despite emerging data 1

5. Verify trileaflet anatomy - the current evidence base and FDA approval specifically applies to trileaflet valves 1

Key Complications to Discuss

TAVR carries specific risks that differ from surgical AVR 1:

• Mortality: 3-5%
• Stroke: 6-7% (higher than surgical AVR's 2%)
• Access complications: 17%
• Pacemaker insertion: 2-9% (Sapien) to 19-43% (CoreValve)
• Paravalvular aortic regurgitation
• Acute kidney injury
• Rare but catastrophic: coronary occlusion, valve embolization, aortic rupture