Centers of Excellence in Interventional Cardiology and Radiology

INTERVENTIONAL CARDIOLOGY

Transcatheter aortic valve insertion – TAVI

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TAVI is the most complex angiographic procedure from the entire world! You need the best specialists!

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Generalities

The heart has four valves (the tricuspid, pulmonary, mitral, and aortic valves). These allow the unidirectional flow of blood between the heart chambers and large vessels.2

Aortic stenosis occurs when the aortic valve, which separates the main pumping chamber of the heart from the circulation, becomes partially narrowed. This causes impaired outflow of blood from the heart and is usually progressive. The increased cardiac workload leads to left ventricular hypertrophy and heart failure. Symptoms of aortic stenosis typically include shortness of breath, exertional chest pain, and even loss of consciousness.

In the majority of cases the aortic stenosis occurs because of an „aging” process, but it can also occur in an innate abnormal valve. A rare cause is rheumatic valvular heart disease. While medical treatment can improve the symptoms, the only way of stopping the evolution towards a terminal cardiac disease is aortic valve replacement.

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Until recently, aortic valve replacement was made only surgically.

Surgical aortic valve replacement with an artificial (biological or mechanical) prosthesis is the conventional treatment for patients with severe symptomatic aortic stenosis who are suitable for surgery.

However, patients may be unsuitable for surgical aortic valve replacement because of medical comorbidities or because of technical considerations (i.e., if the patient has a calcified aorta, or scarring from previous cardiac surgery) which mean that the risks of surgical aortic valve replacement outweigh the potential benefits.

In the last ten years, a new technique has been developed – the transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation may be an alternative to surgical valve replacement in patients for whom conventional aortic valve replacement is not suitable, or who at very high risk.

Indications

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TAVI is indicated for patients presenting a severe aortic stenosis (assessed echocardiographically) who are highly symptomatic, for whom the procedure is expected to bring a major clinical benefit.

Procedure

The procedure is performed through a tube, which is usually inserted into the femoral artery at the top of the leg (transluminal approach), but it could also be inserted into the apex of the heart (transapical approach). Through this tube, a valve is inserted and deployed over the faulty native valve. Each technique has certain indications and contraindications, and the technique is established by a multidisciplinary team (a cardiologist, a cardiac surgeon, and an anesthesiologist) after specific exams are made.

TAVI aims to provide a less invasive alternative to open cardiac surgery for the treatment of aortic stenosis, avoiding the need for cardiopulmonary bypass. The procedure is carried out under general anaesthesia or using local anaesthesia with sedation. Imaging guidance (including fluoroscopy, angiography and transoesophageal echocardiography) is required.

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Prophylactic antibiotic and anticoagulation therapy is administered before and during the procedure. Temporary peripheral extracorporeal circulatory support (usually via the femoral vessels) is sometimes used. The procedure involves the implantation of a bioprosthetic aortic valve at the site of the native aortic valve.

Access to the aortic valve can be achieved

transluminally, with entry into the circulation usually achieved via the femoral or other large artery or vein (sometimes known as a percutaneous, orendovascular approach);

or surgically, with access to the aortic valve via an apical puncture of the left ventricle using a mini thoractomy approach (transapical, or transventricular approach).

In the case of transluminal approach, if the femoral vein is used, the interatrial septum must be punctured in order to gain access to the left ventricle via the left atrium and mitral valve; if the femoral or other large artery is used, surgical exposure and closure may be required. The choice of how the catheter access to the aortic valve is achieved may depend on the existence of other factors that may make passage through the circulation difficult, such as peripheral vascular disease.

A balloon catheter is advanced over a guidewire placed across the aortic valve. The existing aortic valve is dilated and a new prosthetic valve is manipulated into position and placed over the existing aortic valve. In order to provide a stable platform for aortic valve implantation, rapid pacing of the right ventricle is used to temporarily interrupt blood flow through the native aortic valve. The new valve is mounted on a metal stent which is either self-expanding or expanded using inflation of a large balloon on which the stented valve has been compressed. Positioning of the new valve leads to obliteration of the native aortic valve. The delivery catheter is removed after successful valve placement.

Risks

TAVI has a success rate > 95%. However, as any medical procedure, it carries out certain risks which depend from patient to patient. The risks will be explained by the cardiologist on an individual basis, depending on each patient’s associated medical conditions.

Potential risks are : death (<10% of all cases- as a direct consequence of the procedure or secondary to other periprocedural or postprocedural complications), stroke (<5% of all cases), myocardial infarction (<2%), renal failure (<5%), emergent cardiac surgery (<5%), hemorrhage requiring transfusion, vascular surgical intervention of the vessels at the top of the leg , allergic reactions to contrast agents, pericardial bleeding, infections, cardiac arrhythmias, heart block requiring the implantation of a permanent pacemaker.

Before procedure

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Before deciding if TAVI is the optimal procedure, the patient will be carefully assessed (electrocardiogram, thoracic x-ray, blood tests, transthoracic echocardiography TTE, sometimes thransesophageal echocardiography TEE, coronary angiography, angiography or CT of the femoral arteries – through which the prosthesis will be introduced, Doppler echocardiography of the arteries, respiratory functional tests, dental exam); any infectious process needs to be excluded before performing the procedure.

After procedure

All patients are initially monitored in the intensive care unit. All the catheters are removed (usually in the first 24-48 hours) to allow a rapid mobilization. A dual-antiplatelet by aspirin and clopidogrel will be taken for a period of 3 months after the procedure. Total hospitalisation time is less than a week if there are no complications.

A series of exams including imaging and blood tests will be carried out in the first days in order to assess the results of the intervention. After discharge, patients are enrolled in a physical training program.

All patients will be given a date for a follow-up appointment to check on their progress (usually after a month, then after 3 months – 6 months, then yearly – depending on evolution).

Important!

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Aortic stenosis is a severe disease. From symptom onset, without intervention, life expectancy is reduced at several years. The only way of stopping the progression to a terminal cardiac disease is aortic valve replacement.

While the majority of patients can benefit of open-heart surgery, there are many high-risk patients for whom the classical surgical intervention carries a high risk of complications and death, who can alternatively benefit of implantation of an aortic valve prosthesis transluminally (TAVI).

DOCTORS
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