From the Guidelines
TAVR is recommended for patients with severe symptomatic aortic stenosis who have a prohibitive risk for surgical AVR and a predicted post-TAVR survival greater than 12 months. This recommendation is based on the 2014 AHA/ACC guideline for the management of patients with valvular heart disease, which suggests that TAVR can improve survival and reduce symptoms in high-risk patients with severe symptomatic AS 1. The guideline defines prohibitive risk as a predicted risk of death or major morbidity of >50% at 1 year, disease affecting ≥3 major organ systems that is not likely to improve postoperatively, or anatomic factors that preclude or increase the risk of cardiac surgery.
Key considerations for TAVR include:
- Severe symptomatic AS, defined as an aortic valve area <0.8 cm plus a mean pressure gradient ≥40 mm Hg or a maximum aortic velocity ≥4.0 m per second
- Prohibitive risk for surgical AVR, including comorbid disease or serious irreversible conditions
- Predicted post-TAVR survival greater than 12 months
- Comprehensive cardiac imaging, including echocardiography, CT angiography, and cardiac catheterization, to assess valve anatomy and vascular access
Potential complications of TAVR include:
- Vascular injury
- Stroke
- Paravalvular leak
- Conduction abnormalities requiring pacemaker implantation Regular follow-up with echocardiography is essential to monitor valve function and detect any complications early. The PARTNER trial, which used the Edwards Sapien Valve, demonstrated the effectiveness of TAVR in improving survival and reducing symptoms in high-risk patients with severe symptomatic AS 1. However, the most recent and highest quality study, the 2014 AHA/ACC guideline, takes precedence in guiding clinical decision-making 1.
From the Research
Cardiac TAVR Overview
- Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure used to treat severe aortic stenosis (AS) in patients who are at high risk for surgical complications 2, 3.
- TAVR has become the preferred treatment option for patients with symptomatic severe AS, and its indications have expanded to include patients with bicuspid aortic valve, small aortic annuli, low-flow, low-gradient AS, and younger patients 2.
- The procedure has shown promising results, with equivalent or superior outcomes compared to traditional surgical aortic valve replacement (SAVR) 3.
Patient Selection and Outcomes
- Patient selection is crucial for TAVR, and careful evaluation of preoperative risk factors is necessary to ensure optimal outcomes 4.
- TAVR has been shown to be beneficial for patients with severe AS who are at high risk for surgical complications, with potential benefits including reduced periprocedural complications and improved quality of life 4.
- However, TAVR is not without risks, and potential harms include perioperative death, myocardial infarction, stroke, bleeding, and valve embolization 4.
Advances and Future Directions
- Recent advances in TAVR technology have expanded the eligible population to include patients with asymptomatic severe and moderate AS, as well as those with native aortic regurgitation 2.
- The use of dedicated devices to treat native aortic regurgitation has shown encouraging short-term outcomes, and valve-in-valve TAVR has shown promising midterm results 2.
- Ongoing clinical trials are expected to provide further guidance on antithrombotic therapy and other aspects of TAVR management 5.
Complex Cases and Combined Procedures
- TAVR can be performed in combination with other procedures, such as thoracic endovascular aortic repair (TEVAR), to treat patients with complex aortic pathology 6.
- The one-stop TEVAR + TAVR procedure has been shown to be viable and beneficial in patients with severe AS and concurrent aortic pathology 6.