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Transcatheter Aortic Valve Replacement
Background
The most common valvular disease of the heart in adults is aortic stenosis (AS) with a noted increased incidence with aging. , Patients typically experience a slow decline in the aortic valve area over many years. The tipping point is the development of symptoms, after which there is increased mortality if the AS is left untreated. , Patients may experience shortness of breath, chest discomfort, syncope, or may present with heart failure. Surgical aortic valve replacement (SAVR) has been known to improve survival and leads to a resolution of symptoms. However, mortality and risk of complications from operative repair increases with age, and many patients are therefore unable to undergo SAVR. Transcatheter aortic valve replacement (TAVR or transcatheter aortic valve implantation [TAVI]) is the minimally invasive insertion of a bioprosthetic valve, and it is approved by the Food and Drug Administration for patients who are at high, intermediate, or low risk for SAVR. Clinical trials have demonstrated similar outcomes overall for patients following TAVR versus SAVR, with TAVR generally demonstrating fewer adverse events and the procedure is typically well tolerated. ,
How to Use It
The diagnosis of severe AS is made with echocardiography. See Chapter 25: Echocardiography for more details about this test. Patients may have a characteristic systolic murmur on examination or symptoms such as shortness of breath, chest discomfort, or syncope that prompts the test. The indications for TAVR include patients with severe symptomatic AS. The decision regarding SAVR or TAVR is typically made in conjunction with the heart team (which includes interventional cardiology and cardiothoracic surgery) and will factor in the patient’s surgical risk and anatomy. Once the decision has been made to proceed to TAVR, the patient will undergo computed tomography imaging of the chest to evaluate the patient’s anatomy and determine the proper valve that will be utilized for the procedure. The patient will also undergo cardiac catheterization to evaluate for the presence of coronary artery disease. See Chapter 17: Computed Tomography Scan and Chapter 46: Percutaneous Coronary Intervention for more details about these tests.
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