Is Transcatheter Aortic Valve Implantation (TAVI) indicated for this patient?

TAVI Indications and Patient Selection

TAVI is indicated only for high-risk patients with severe symptomatic aortic stenosis who are unsuitable for conventional surgery or have prohibitive surgical risk, as determined by a multidisciplinary heart team. 1, 2

Patient Selection Criteria

Clinical Indications

• Severe symptomatic calcific aortic stenosis
• High surgical risk (STS score ≥8%) or prohibitive surgical risk (≥50% risk of mortality/morbidity at 30 days)
• Life expectancy >12 months
• Expected improvement in quality of life after procedure

Absolute Contraindications

1. Absence of a "heart team" and no cardiac surgery on-site
2. Life expectancy <1 year
3. Unlikely improvement in quality of life due to comorbidities
4. Severe disease of other valves requiring surgical treatment
5. Active endocarditis
6. Thrombus in left ventricle
7. Mobile thrombi in ascending aorta or arch

Anatomical Considerations

• Aortic annulus size must be appropriate (18-25mm for balloon-expandable, 20-27mm for self-expandable devices)
• Bicuspid valves are generally contraindicated due to risk of incomplete deployment
• Adequate vascular access for chosen approach
• Risk assessment for coronary ostium obstruction
• Evaluation of peripheral vasculature (for transfemoral approach)

Evaluation Process

Required Imaging

1. Echocardiography: Assess valve morphology, annulus size, and LV function
2. Coronary angiography: Evaluate coronary anatomy and need for revascularization
3. CT/MRI: Assess peripheral vasculature, aortic root dimensions, and valve calcification

Heart Team Approach

A multidisciplinary team including cardiologists, cardiac surgeons, imaging specialists, and anesthesiologists must evaluate each patient to:

• Confirm severity of aortic stenosis
• Assess surgical risk
• Evaluate anatomical suitability
• Choose appropriate access route
• Determine valve size and type

Procedural Considerations

Access Routes

• Transfemoral: Preferred approach if anatomically suitable
• Transapical: Alternative for patients with severe peripheral vascular disease
• Transsubclavian/axillary: Additional alternative access routes

Contraindications for Transfemoral Approach

• Severe iliac/femoral calcification or tortuosity
• Small vessel diameter (<6-9mm depending on device)
• Severe angulation of aorta
• Bulky atherosclerosis of ascending aorta/arch

Expected Outcomes and Complications

Benefits

• Significant reduction in mortality compared to medical therapy (30.7% vs 50.7% at 1 year) 3
• Improved symptoms and quality of life
• Reduced rehospitalization rates

Potential Complications

• Stroke (5-7%)
• Vascular complications (16-17%)
• Need for permanent pacemaker
• Paravalvular regurgitation
• Acute kidney injury

Key Pitfalls to Avoid

1. Performing TAVI in centers without cardiac surgery capability
2. Selecting patients with life expectancy <12 months
3. Underestimating comorbidities that would limit benefit
4. Inadequate imaging assessment of aortic annulus size
5. Overlooking severe calcification patterns that increase procedural risk
6. Choosing inappropriate valve size

Conclusion

When evaluating whether TAVI is indicated for a specific patient, the decision must be made by a multidisciplinary heart team after thorough clinical and anatomical assessment. TAVI should be reserved for patients with severe symptomatic aortic stenosis who are at high or prohibitive surgical risk but have suitable anatomy and reasonable life expectancy to benefit from the procedure.