When TAVR over SAVR?
- “porcelain” aorta
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- risk of cross-clamping the calcific aorta
- Factors that ↑ cardiac surgical risk, e.g. prior chest radiation, severe lung, liver, or renal disease
Management
- Antiplatelet: aspirin 75 to 100 mg daily is reasonable in the absence of other indications for oral anticoagulants (Class 2a)
When palliation over TAVR?
- limited life expectancy (<12 months)
- irreversible severe LV dysfunction
- dementia
- severe frailty
- difficult aortic anatomy (annular size, calcium below valve, coronary location)
- difficult vascular access
- moderate or severe multiple-organ system disease
Complications
Paravalvular Leak
- If present, associated with a worse short- and long-term survival.1
- Paravalvular regurgitation is more common with TAVR than with SAVR
- Hemodynamic consequences arise b/c the LV has been used to being non-compliant and under pressure load for years, and now is facing a sudden ↑ volume load from the AR
- Why PVLs after TAVI? Reasons include:
- suboptimal placement of the prosthesis with incomplete sealing of the annulus by the valve stent,
- incomplete approximation of the valve stent frame due to annular calcium or the native valve leaflets, or
- undersizing of the TAVI valve
- Use of 3D imaging, “oversizing” algorithms, newer-generation valves w/ sealing membranes/skirts to occupy the residual interstices have helped to reduce the rates of PVL.
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Footnotes
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Pibarot, P., Hahn, R. T., Weissman, N. J., Arsenault, M., Beaudoin, J., Bernier, M., Dahou, A., Khalique, O. K., Asch, F. M., Toubal, O., Leipsic, J., Blanke, P., Zhang, F., Parvataneni, R., Alu, M., Herrmann, H., Makkar, R., Mack, M., Smalling, R., … Kodali, S. (2017). Association of Paravalvular Regurgitation With 1-Year Outcomes After Transcatheter Aortic Valve Replacement With the SAPIEN 3 Valve. JAMA Cardiology, 2(11), 1208. https://doi.org/10.1001/jamacardio.2017.3425 ↩