Abstract
Résumé
Introduction
ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.
The TAVI procedure
Valve function
Registry Data

Who Should Undergo TAVI?
TAVI in nonoperable patients
- Reynolds M.R.
- Magnuson E.A.
- Wang K.
- et al.
Health-related quality of life after transcatheter or surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial (cohort A).
TAVI in high-risk operable patients
- Reynolds M.R.
- Magnuson E.A.
- Wang K.
- et al.
Health-related quality of life after transcatheter or surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial (cohort A).
TAVI in intermediate- and low-risk patients
ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.

- 1Transfemoral TAVI is recommended if:
- aThe risk of open heart surgery is prohibitive; and
- bA significant improvement in duration or quality of life is likely; and
- cLife expectancy with treatment is likely to exceed 1 to 2 years
- a
- 2Patients who are not candidates for open heart surgery or for TAVI using femoral artery access may be considered for other alternative access procedures (eg, transapical, transaxillary, or transaortic) (Conditional Recommendation, Low-Quality Evidence).
- 3TAVI is a reasonable alternative to SAVR for patients at high risk (“high risk” can be defined as a risk of mortality of ≥ 8% or major morbidity of > 50% within 30 days of surgery as predicted by an experienced cardiac surgeon or by the STS risk calculator) of mortality or major morbidity and:
- aDuration and quality of life is likely to be significantly improved by treatment
- bLife expectancy with treatment is likely to exceed 1 to 2 years with treatment
- cThere is a consensus amongst a multidisciplinary Heart Team including cardiologists and surgeons
- a
- 4SAVR is the treatment of choice for patients diagnosed with severe symptomatic AS considered at intermediate or low surgical risk (Strong Recommendation, Moderate-Quality Evidence).
- 5TAVI may be offered to selected patients with severe symptomatic AS who would otherwise be considered intermediate to low risk of mortality where there is a consensus of the Heart Team that they are at significantly increased risk of either morbidity or mortality due to special circumstances (eg, frailty, very advanced age, patent bypass grafts, multivalve disease, etc) (Conditional Recommendation, Low-Quality Evidence).
Valve-in-valve implants
ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.
- 1Surgical valve replacement is the treatment of choice for non-high risk patients with failure of bioprosthetic surgical valves (Strong Recommendation, Low-Quality Evidence).
- 2Transcatheter valve-in-valve implants may be reasonable in patients with failed surgical bioprosthetic valves in whom there is a Heart Team consensus that:
- aThe risk of open heart surgery is prohibitive; and
- bA significant improvement in duration or quality of life is likely; and
- cLife expectancy with treatment is likely to exceed 1 to 2 years; and
- dThe dimensions and characteristics of the failed valve are understood and compatible with good transcatheter valve function
- a
- 3Transcatheter valve implants is reasonable in carefully selected patients with transcatheter valve failure (Conditional Recommendation, Low-Quality Evidence).
Evaluation for TAVI

Assessment of aortic valve anatomy and function
ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.
Measurement of the aortic annulus
Assessment of LV anatomy and function
Assessment of coronary anatomy
Assessment of arterial access
Functional assessment
Surgical risk
- 1Screening for TAVI should include all of the following:
- aA comprehensive assessment of medical history
- bA complete physical examination with special attention to signs of severe AS, lung disease, and peripheral artery disease; objective evaluation of neurocognitive function and frailty is encouraged; exercise testing or standardized walk tests may be helpful
- cElectrocardiogram, chest X ray, complete blood count, electrolytes, creatinine, liver function; brain natriuretic peptide may be helpful
- dTTE with an assessment of annulus diameter; low-dose dobutamine stress echocardiography may be helpful in patients with severely reduced LV function and a low transaortic gradient
- eTEE to assess the annulus diameter is recommended, particularly in the absence of MSCT measurements
- fCoronary angiography
- gAortography and ilio-femoral invasive angiography or MSCT angiography, preferably both
- hAccurate measurement of aortic annulus size by TEE and/or MSCT or MRI is key for appropriate selection of prosthesis size
- a
Program Principles
The multidisciplinary team
TAVI training
- 1The multidisciplinary heart team should include:
- aInterventional cardiologists
- bCardiac surgeons
- cImaging specialist
- dCardiac anaesthetist
- eExperienced nurses
- a
- 2Primary operators should perform a minimum of 25 cases per year (Strong Recommendation, Low-Quality Evidence).
- 3Training of a TAVI operator should include:
- aDidactic theoretical sessions for 1 day, as a minimum
- bSimulator training
- cObservation of 2 to 5 TAVI cases, as a minimum
- dSupport for the initial 5 to 10 cases by a proctor, as a minimum
- eNew physicians in the field should have performed a12-month training in structural heart disease, as a minimum
- a
The TAVI procedure room
Procedural volume
- 1Institutions should perform a minimum of 25-50 cases per year (Strong Recommendation, Low-Quality Evidence).
- 2TAVI should be performed in centres with:
- aEstablished clinical excellence
- bA large experience in high risk aortic valve surgery
- cA commitment to a comprehensive valve program
- dA strong, collaborative multidisciplinary Heart Team
- eThe ability to provide ongoing quality improvement
- fThe ability to participate in ongoing research
- a
- 3TAVI programs should have ready access to:
- aTTE and TEE
- bMSCT
- cA specially equipped cardiac catheterization lab or hybrid operating room
- dCardiac surgery
- ePerfusion services
- fA surgical recovery area
- gAn intensive care unit
- hRenal replacement therapy
- iVascular surgery
- jPeripheral vascular interventional expertise
- a
Postprocedural Management
- Wilson W.
- Taubert K.A.
- Gewitz M.
- et al.
TAVI Cost
- Reynolds M.R.
- Magnuson E.A.
- Wang K.
- et al.
Health-related quality of life after transcatheter or surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial (cohort A).
Conclusion
References
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Article Info
Publication History
Footnotes
The disclosure information of the authors and reviewers is available from the CCS on the following websites: www.ccs.ca and/or www.ccsguidelineprograms.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.