What is the diagnosis and treatment plan for a patient with ischemic heart disease, valvular heart disease with severe aortic stenosis, and complicated cardiomyopathy, planned for Transcatheter Aortic Valve Implantation (TAVI) protocol, including Computed Tomography (CT) whole aorta and CT coronary angiography, and diagnostic coronary angiography?

From the Guidelines

The patient with ischemic heart disease, severe aortic stenosis, and cardiomyopathy should undergo Transcatheter Aortic Valve Implantation (TAVI) with prior CT imaging of the whole aorta and CT coronary angiography, as well as diagnostic coronary angiography to assess coronary artery disease severity and guide potential additional interventions. This approach is supported by recent guidelines, including the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1, which emphasizes the importance of comprehensive evaluation before TAVI. The use of CT coronary angiography as an alternative to coronary angiography in selected patients is also recommended, especially for those at low to intermediate pretest probability of CAD before valve surgery 1.

Key Considerations

• The patient's condition, including severe aortic stenosis and cardiomyopathy, necessitates a thorough evaluation to determine the best treatment approach.
• TAVI is a viable option for patients at intermediate or high risk for traditional surgical valve replacement, offering benefits such as shorter recovery times and reduced complications compared to open surgery 1.
• Diagnostic coronary angiography is crucial for assessing coronary artery disease severity and determining the need for additional interventions before valve replacement.
• The choice between TAVI and surgical aortic valve replacement (SAVR) should be based on a shared decision-making process, considering factors such as vascular access, comorbid conditions, expected functional status, and patient preferences 1.

Pre-Procedural Care

• The patient should continue all current cardiac medications until instructed otherwise by their cardiologist.
• A low-sodium diet should be maintained to reduce fluid retention and alleviate symptoms.
• Daily weight monitoring is essential to quickly identify any significant changes that may indicate worsening heart failure.
• The patient should report any worsening symptoms, such as increased shortness of breath or chest pain, to their healthcare provider promptly.
• Pre-procedure instructions regarding medication adjustments and fasting requirements should be followed carefully to minimize risks associated with the procedure.

From the Research

Diagnosis Details

• Ischemic heart disease with valvular heart disease severe aortic stenosis complicated with cardiomyopathy
• Planned for TAVI protocol
• CT whole aorta and CT coronary angiography
• Diagnostic coronary angiography

Treatment Plan

• Transcatheter aortic valve implantation (TAVI) has become a safe and indispensable treatment option for patients with severe symptomatic aortic stenosis (AS) who are at high or prohibitive surgical risk 2
• TAVI has emerged as a qualified alternative to surgical aortic valve replacement (SAVR) in the treatment of intermediate risk patients 2
• The best way to treat patients with concomitant coronary artery disease (CAD) undergoing TAVI is contentious, and conventional assessments of ischaemia such as fractional flow reserve (FFR) and instantaneous wave-free ratio are not validated in the context of severe AS 3
• Noninvasive cardiac imaging modalities can anatomically delineate or functionally assess for significant coronary artery stenosis, as well as detect the presence of myocardial infarction (MI) 4
• Coronary CT angiography can help assess the degree of anatomic stenosis, but its inability to assess the physiologic significance of lesions limits its specificity 4
• Physiologic significance of coronary artery stenosis can be determined by cardiac MR vasodilator or dobutamine stress imaging, CT stress perfusion imaging, FFR CT, PET myocardial perfusion imaging (MPI), SPECT MPI, and stress echocardiography 4

Assessment and Management of CAD

• Approximately 50% of individuals eligible for TAVI have coronary artery disease (CAD) 5
• The influence of CAD on post-TAVI clinical results has yielded conflicting findings 5
• Recent research has shown positive results for the use of computed tomography angiography and functional percutaneous evaluation of coronary lesions in the pre-TAVI assessment, besides the classic coronary angiography 5
• It has become common practice to perform invasive revascularization on TAVI patients with obstructive CAD 5

Risks and Complications

• Stroke after TAVI is a relatively rare, but serious complication, associated with potential prolonged disability and increased mortality 6
• The overall incidence of 30-day stroke in TAVI patients is 3%-4%, but varies between different trials 6
• Predictors of acute stroke are mainly procedure related, whereas late stroke is mainly associated with patient characteristics, with a variable impact on cognitive function 6