Chapter 42. Patient Selection, Procedural Techniques, and Complications of Balloon-Expandable Transcatheter Aortic Valve Replacement
What are the current indications for transcatheter aortic valve replacement (TAVR)?
A. Patients with severe symptomatic aortic stenosis (AS) who are at prohibitive/high surgical risk
B. Patients with severe symptomatic AS who are at intermediate surgical risk
C. “Valve-in-valve” therapy for patients with bioprosthetic aortic valve failure
D. Patients with severe symptomatic aortic regurgitation who are at prohibitive surgical risk
Results from the PARTNER trial have allowed TAVR to become the standard of care for prohibitive risk patients with severe AS and to be seen as a valid alternative to surgery for high surgical risk patients. In 2016, TAVR received US Food and Drug Administration (FDA) approval for patients with severe AS who are at intermediate risk for death or complications associated with open-heart surgery (Society of Thoracic Surgeons [STS] risk score of 4%-8%). In 2015, the FDA approved an expanded indication to include “valve-in-valve” repair of failed surgical bioprosthetic aortic valves. Currently, there are no transcatheter valves that have been FDA approved for the treatment of severe symptomatic aortic regurgitation. In Europe, a TAVR system (JenaValve) is an option to treat severe native aortic valve regurgitation in patients with high or greater risk for open surgical valve replacement or repair.
What is the preferred access site for TAVR?
The transfemoral (TF) method is the most commonly used approach, with the majority of TAVR devices being deployed by this technique. TF procedures are now performed using a fully percutaneous “preclosure” technique as described. Advantages of the TF technique include the fact that it is the least invasive approach and can be performed in most patients with lower profile delivery systems (14 and 16 Fr). Most local vascular complications, including dissection, can be managed with endovascular techniques.
True or false? TF TAVR under conscious sedation can be performed with minimal morbidity and mortality compared to TF TAVR under general anesthesia.