ESC Focus on Interventions & PC - 14

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TAVI/TAVR Summit
Written by Phil Vinall

The 2014 AHA/ACC Guidelines for the Management of
Patients with Valvular Heart Failure [Nishimura RA et
al. Circulation. 2014] specified that the following factors
should be considered when selecting patients for transcatheter aortic valve replacement (TAVR): Society of
Thoracic Surgeons (STS) risk score, frailty, major organ
system compromise not to be improved post surgery, and
the presence and level of procedure-specific impediment.
Using these criteria, patients were defined as being at low,
intermediate, high, or extreme/inoperable risk. A focused
update was issued recently that includes changes to some
of the indications for TAVR based on risk data accumulated from the many clinical trials conducted since 2014
(Figure 1) [Nishimura RA et al. Circulation. 2017]. Martin B.
Leon, MD, Columbia University Medical Center, New York
City, New York, USA, reviewed some of these changes in the
Aortic Valve Interventions Symposium on 26 August 2017.
In the high surgical-risk group, there are small differences favouring TAVR over surgery at all mortality
outcomes [Smith CR. N Engl J Med. 2011]. In intermediate- or moderate-risk patients, the outcomes of death
and disabling stroke are similar for TAVR and surgical
aortic-valve replacement [Leon MB et al. N Engl J Med.
2016]. Key findings from recent studies show there are
fewer vascular complications with surgery, but TAVR
offers improved rates for mortality, strokes, severe
bleeding, new onset atrial fibrillation (AF), and quality of
life. For lower-risk patients, treatment choice should be
based on whether the known value of less-invasive TAVR
versus open surgery outweighs the unknown long-term
durability of TAVR. In Dr Leon's opinion, surgical risk is
important but clinical (eg, age, frailty, the presence of
chronic obstructive pulmonary disease, liver or kidney
disease, dementia) and anatomic (eg, heavily calcified
Figure 1. 2017 AHA/ACC TAVR Guidelines
Class IIa

Severe AS Symptomatic
(stage D)

Class I

Low
Surgical Risk

Surgical AVR
(Class I)

Intermediate
Surgical Risk

Surgical AVR
(Class I)

TAVR
(Class IIa)

High
Surgical Risk

Surgical AVR or TAVR
(Class I)

Prohibitive
Surgical Risk

TAVR
(Class I)

AS, aortic stenosis; AVR, aortic valve replacement; TAVR, transcatheter aortic
valve replacement.
Reprinted from Nishimura RA et al. 2017 AHA/ACC Focused Update of the
2014 AHA/ACC Guideline for the Management of Patients With Valvular
Heart Disease: A Report of the American College of Cardiology/American
Heart Association Task Force on Clinical Practice Guidelines. Circulation.
2017;135:e1159-e1195. Copyright ©2017. With permission from the American
Heart Association.

October 2017

aorta, concomitant disease, risk of coronary artery
occlusion or rupture) factors must also be considered.
Eberhard Grube, MD, Heart Center Bonn, Germany,
and Stanford University, School of Medicine, Palo Alto,
California, USA, presented unusual complications he
encountered during a transcatheter aortic valve implantation (TAVI) procedure. The first involved an undetected
ventricular septal defect that led to sudden drop in blood
pressure, an increase in wedge pressure, and a decrease
in oxygen saturation. The defect was only detected by
colour echo. The procedure continued after the defect
was patched, but the patient died 10 days later. Lesson
learned? Be prepared. Have all the equipment in different sizes and amounts; know the differential diagnosis of
hypotension after valvuloplasty; realise that TAVI complications might occur even at remote sites. In the second
case, Dr Grube encountered difficulty during catheter
placement due to aorta and wire kinking. Three different catheters were needed before success was achieved.
Lesson learned? Have various TAVR devices on the shelf.
Transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) are the mainstays
for diagnosis/quantification and therapy induction, as
well as evaluation of complications and success during follow-up. Michel Zuber, MD, Heart Team, University
Hospital, Zurich, Switzerland, believes standard TOE
guidance in general anaesthesia during TAVI/TAVR will
be replaced by a minimalistic approach with sedation
without TOE, with equivalent safety and efficacy outcomes in very experienced centres. TTE will then be
important for the diagnosis/treatment of intra-procedural emergencies. TOE will continue to be necessary
to confirm valve size and for continuous monitoring in
patients with renal dysfunction without preinterventional computed tomography (CT).
However, guidelines recommend TOE for intraprocedural confirmation of the landing zone morphology
and measurements, positioning of the valve, and postprocedural evaluation of complications [Hahn RT et al.
JACC Cardiovasc Imaging. 2015]; while general practice
data supports its value as a protective factor.
On the other hand, a comparison of transfemoral TAVR
using sedation/TTE versus intubation/TOE showed TTE
with sedation was associated with similar safety and
efficacy outcomes as the standard TOE procedure in
very experienced centres, but sedation/TTE resulted in
shorter hospital stays and intervention times, and significantly lower cost [Babaliaros V et al. JACC Cardiovasc
Interv. 2014]. Although TAVI may be performed under

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