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Pre-operative workup for TAVI

What is TAVI?

TAVI stands for Transcatheter Aortic Valve Implantation. This is a revolutionary minimally invasive surgical procedure that replaces damaged aortic valves in the heart with new valves. The new valve is placed within the diseased valve and is sometimes called Transcatheter Aortic Valve Replacement (TAVR).

This procedure is the current treatment method of choice for severe aortic stenosis (AS). Here, the aortic valve becomes extremely narrow, hindering the blood flowing through it. It leads to chest pain, fatigue, shortness of breath, etc., leading to heart failure or sudden cardiac death.

In TAVI, various methods are used to access the aortic valve. Using angiographic techniques, a catheter is passed up either the femoral artery in the leg (transfemoral approach) or large vessels in the chest or the heart’s left ventricle (transapical approach), to reach the narrowed aortic valve. The new valve is appropriately positioned using different methods, and this will renew function of the valve to its previous state.

This method is preferable over the conventional Surgical Aortic Valve Replacement (SAVR), which is associated with higher risk and longer surgeries, as proved by several trials.

Why is a Pre-Operative assessment needed?

A thorough pre-operative assessment is a must in any surgical situation. The main reason is to ensure that the surgical and anesthetic procedures performed will not have any detrimental effects and that the patient will tolerate them. TAVI is usually carried out under local anesthesia, but suitability for general anesthesia must also be checked in case it is needed during surgery. An assessment is also required to conclude that the surgery is necessary, and the indications are present such that the outcome of surgery is more beneficial than the risks involved. Imaging also plays a crucial role in planning the procedure.

What is required in the Pre-Operative assessment?

A standard TAVI workup includes

  • Clinical assessment – To determine the indication for TAVI and its urgency.
  • Surgical and Frailty risk scoring – This is done using various scoring systems like ACS NSQIP etc.
  • Blood investigations – Like a Full Blood Count, blood biochemistry panel, liver function tests, coagulation studies, arterial blood gases, random blood sugars, etc.
  • Echocardiography – This is important to assess the status of the aortic valve, which influences the surgery. Also, the ejection fraction is measured, which is a strong indicator of surgical mortality.
  • Pulmonary function tests, including chest x-ray – Any lung abnormalities must be found beforehand and dealt with, as it can affect the outcome of the surgery.

Special pre-op workup requirements for TAVI are as follows;

  • Access route evaluation
    1. Usually, the transfemoral route is the typical access point through which the catheter is introduced.
      Iliofemoral angiography is essential to assess the size, tortuosity, and degree of calcification, as these affect catheterization success. CT can also be used to evaluate but is not as effective.
    2. Other access routes, like subclavian and carotid vessels, also need to be imaged using angiography if possible.
  • Hemodynamic assessment – This is essential to grade the degree of aortic stenosis. Echocardiography is the usual non-invasive procedure to measure this, but cardiac catheterization can also provide valuable information regarding chamber pressures and flow rates.
  • Diagnostic coronary angiography – This is required to identify and treat any existing coronary artery disease, as they severely affect the success of the surgery. This can be done via the femoral route due to the concurrent need to assess the femoral vessels. An angiography also provides valuable information regarding coronary Ostia, which affects valve placement.
  • Aortogram clarifies whether the aorta is suitable enough to allow the catheter to pass up to the heart. It also shows the presence, if any, of aortic valve calcifications and co-existing aortic regurgitation, all of which need to be considered before surgery. A transesophageal echo can assist with this as well.
  • Right heart catheterization – This is carried out to assess the presence of pulmonary hypertension, which increases mortality following TAVI.

 

Conclusion

As evidenced by this article, while TAVI is a revolutionary method to treat severe AS with much less mortality, the procedure’s success depends heavily on an excellent pre-op workup. If you are from around Mumbai and feel like TAVI is the way for you, don’t hesitate to contact the offices of Dr. Ankur Phatarpekar, who is the best heart specialist/cardiologist in Mumbai. We will ensure that the proper assessment is done and excellent care is provided to ensure the best outcome for you.

References

  • What is TAVR? (TAVI). www.heart.org. https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/understanding-your-heart-valve-treatment-options/what-is-tavr. Published 2021. Accessed September 14, 2021.
  • Zaman S, Gooley R, McCormick L, Harper R, Meredith I. Pre – Transcatheter Aortic Valve Implantation Workup in the Cardiac Catheterisation Laboratory. Heart, Lung and Circulation. 2015;24(12):1162-1170. doi:10.1016/j.hlc.2015.07.018

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