What are the management options for Aortic Valve Replacement (AVR)?

Management Options for Aortic Valve Replacement (AVR)

For patients with severe aortic stenosis, the primary management options include Transcatheter Aortic Valve Replacement (TAVR) and Surgical Aortic Valve Replacement (SAVR), with selection based on patient risk factors, anatomy, and life expectancy. 1

Patient Selection and Risk Assessment

Risk Stratification

• Low Risk (STS-PROM <4%):

  • SAVR typically recommended, especially in younger patients
  • TAVR may be considered based on anatomy and patient preference

• Intermediate Risk (STS-PROM 4-8%):

  • Either TAVR or SAVR appropriate
  • Decision influenced by frailty, comorbidities, and procedure-specific impediments

• High Risk (STS-PROM >8%):

  • TAVR generally preferred
  • Significant frailty or multiple organ system compromise favors TAVR

• Prohibitive Risk:

  • TAVR if expected benefit exceeds risk
  • Palliative care or balloon aortic valvuloplasty if futility concerns (life expectancy <1 year)

Key Anatomical Considerations

• Bicuspid valves: Feasible for TAVR with appropriate anatomy 2
• Small aortic annuli: Both options viable with device selection considerations 2
• Concurrent surgical needs: SAVR preferred when additional procedures required (e.g., aortic root replacement) 1
• Unsuitable TAVR anatomy: SAVR recommended

TAVR Procedure and Management

Procedural Approaches

• Transfemoral: Preferred access route when feasible
• Alternative access routes:
  • Transaxillary/subclavian
  • Transaortic
  • Transapical

Periprocedural Management

• Anesthesia: General anesthesia or conscious sedation
• Anticoagulation: Heparin during procedure
• Hemodynamic monitoring: Arterial line, central access as needed
• Pacing: Temporary pacemaker for rapid ventricular pacing
• Antibiotic prophylaxis: Standard surgical prophylaxis

Post-TAVR Care

• Early mobilization and extubation when general anesthesia used
• Monitoring: Telemetry, vital signs, access site assessment
• Antithrombotic therapy:
  • Aspirin 75-100mg daily lifelong
  • Clopidogrel 75mg daily for 3-6 months
  • Consider warfarin if atrial fibrillation or venous thromboembolism risk 1

SAVR Procedure and Management

Valve Options

• Mechanical valves:

  • Longer durability
  • Requires lifelong anticoagulation
  • Preferred in younger patients (<50-65 years)

• Bioprosthetic valves:

  • No long-term anticoagulation required
  • Limited durability (10-15 years)
  • Preferred in older patients or those who cannot take anticoagulants

Anticoagulation Management

• Mechanical valves: Lifelong warfarin with target INR 2.0-3.5
• Bioprosthetic valves: Aspirin therapy long-term
• Dental procedures: Maintain anticoagulation with local hemostatic measures 3

Long-term Follow-up for All AVR Patients

Monitoring Schedule

• 30-day follow-up: TAVR team assessment
• 6-month follow-up: Primary cardiologist
• Annual follow-up: Echocardiography and clinical assessment

Imaging Surveillance

• Echocardiography:

  • 30 days post-procedure
  • Annually thereafter
  • Assess for valve function, regurgitation, gradients

• ECG:

  • 30 days post-procedure
  • Annually or with symptoms
  • Consider 24-hour monitoring if bradycardia present

Endocarditis Prevention

• Dental hygiene: Optimal dental care
• Antibiotic prophylaxis: Per AHA/ACC guidelines for all prosthetic valves 1, 3

Comparative Outcomes

Mortality

• High-risk patients: TAVR shows significant mortality benefit (43.3% vs 68.0% at 2 years) compared to medical therapy 4
• Intermediate-risk patients: TAVR is non-inferior to SAVR (12.6% vs 14.0% at 2 years) 5
• Low-risk patients: TAVR shows 40.1% reduction in 30-day mortality compared to SAVR 6

Complications

• TAVR-specific:

  • Higher rates of paravalvular regurgitation
  • Increased need for permanent pacemaker (3.3 times higher than SAVR) 6
  • Higher vascular complications (4.6 times higher than SAVR) 6

• SAVR-specific:

  • Higher rates of acute kidney injury (56% less in TAVR) 6
  • Higher rates of atrial fibrillation
  • Increased transfusion requirements

Reoperation Considerations

• Redo SAVR after TAVR carries 1.74 times higher mortality than redo SAVR after SAVR 7
• Patients with life expectancy beyond a TAVR valve's durability should consider SAVR-first approach if unsuitable for valve-in-valve TAVR 7

Special Considerations

Valve-in-Valve Procedures

• Feasible option for failed bioprosthetic valves
• Shows encouraging mid-term results 2
• May be limited by small valve sizes or specific valve designs

Expanding Indications

• Asymptomatic severe AS
• Moderate AS with early cardiac remodeling
• Native aortic regurgitation with dedicated devices 2

Pitfalls to Avoid

• Underestimating stroke risk with TAVR (13.8% vs 5.5% at 2 years compared to medical therapy) 4
• Overlooking valve durability concerns in younger patients
• Neglecting post-procedure conduction abnormalities that may require pacemaker
• Failing to consider lifetime management strategy including potential future interventions