DIAGNOSIS AND PATIENT SELECTION TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI)

AORTIC STENOSIS IS A PROGRESSIVE DISEASE

Severe aortic senosis is usually defined as a valve area of ≤1.0 cm2 and a maximum velocity of ≥4.0 meters/second or mean pressure gradient ≥40 mm Hg.

Severe aortic stenosis is the result of leaflet calcification or congenital stenosis with severely reduced leaflet opening.1,2

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Severe aortic stenosis makes the heart work harder

Severe aortic stenosis prevents your aortic valve leaflets from opening and closing properly. This makes your heart work harder to pump blood to the rest of your body. A diseased valve affects your health and limits your daily activities.

Symptoms of severe aortic stenosis include, but may not be limited to:

  • Chest pain
  • Dizziness
  • Fatigue
  • Out of breath
  • Irregular heartbeat

 

aotic valve
aotic valve

Aortic stenosis assessment

Cardiac auscultation

Purpose:
Detect heart valve disease.

Evaluates:

  • Heart sounds with stethoscope
  • Systolic ejection murmur

Attention: Low flow, low gradient (LF/LG) aortic stenosis cannot be detected by auscultation. Therefore, auscultation should not be relied on to exclude valve disease.

Exercise 
Testing

Purpose:
Detect symptoms and prognostic information during exercise.

Evaluates:

  • Risk stratification
  • Asymptomatic cases
  • Cardiac origin of dyspnoea

man on a machine

Echo-
Cardiography

Purpose:
Key diagnostic tool, which confirms aortic stenosis.
 

Evaluates:

  • Primary lesion, cause and severity of valve calcification
  • Hemodynamics, secondary lesions
  • Chamber size and function
  • Wall thickness

Computed Tomography

Purpose:
Detect aortic valve calcium load. Relevant for TAVI patient workup and pre-procedural planning.

Evaluates:

  • Calcium score
  • Exclusion of measurement errors in LF/LG
  • Coronary anatomy
  • Prosthesis sizing and access points

Cardiac 
Catherization

Purpose:
Provide additional information beyond initial findings and is restricted to patients with inconclusive non-invasive investigations.

Evaluates:

  • Pressures and cardiac output 
  • Assessment of ventricular performance
  • Severity of regurgitation
     

Guidelines for aortic valve replacement
in patients with severe aortic stenosis

From the 2017 ESC/EACTS guidelines for the management of valvular heart disease3

Intervention is indicated in symptomatic patients with:

class and level for Aortic Valve

Severe, high-gradient aortic stenosis

  • Aortic valve area (AVA) <1cm2 AND mean gradient ≥40mmHg or peak velocity ≥4.0 m/s
  • Non-reversible high flow status with gradient aortic stenosis also considered severe

class and level for Aortic Valve

Severe, low flow, low-gradient aortic stenosis with reduced ejection fraction and evidence of flow (contractile) reserve excluding pseudo-severe aortic stenosis.

  • AVA <1cm2 AND mean gradient <40 mmHg AND peak velocity <4.0 m/s
  • Reduced ejection fraction <50% Stroke Volume Index (SVi) ≤35 mL/m2
  • Dobutamine Echo with evidence of flow reserve excluding pseudo-severe aortic stenosis

Patient Evaluation for treatment3

Essential questions in the evaluation of patients for valvular intervention:

Patient evaluation treatment graph

Management of severe aortic stenosis3

diagram of patient symptoms

AS = Aortic Stenosis; LVFT = Left Ventricular Ejection Fraction; SAVR = Surgical Aortic Valve Replacement; TAVI = Transcatheter Aortic Valve Implantation.

a Surgery should be considered (lla C) if one of the following is present: peak velocity > 5.5m/s; severe valve calcification + peak velocity progression ≥ 0.3m/s per year; markedly elevated neurohormones (> threefold age-and sex-corrected normal range) without other explanation; severe pulmonary hypertension (systolic pulmonary artery pressure > 60 mmHG).

b See tables of recommendation in ESC/EACTS guidelines published here

Aspects to be considered by the heart team 
for the decision between SAVR AND TAVI3

In patients at increased surgical riska

clinical characteristics graph

cardiac conditions in addition to Aortic Stenosis

anatomical and technical aspects

CABG = Coronary Artery Bypass Grafting; CAD = Coronary Artery Disease; EuroSCORE = European System for Cardiac Operative Risk Evaluation; LV = Left Ventricle; SAVR = Surgical Aortic Valve Replacement; STS = Society of Thoracic Surgeons; TAVI = Transcatheter Aortic Valve Implantation; Frailty: Poor mobility, as assessed by the 6-minute walk test, and oxygen dependency are the main factors associated with increased mortality after TAVI and other VHD treatments. The assessment of frailty should not rely on a subjective approach, such as the ‘eyeball test’, but rather on a combination of different objective estimates.

a  STS or EuroSCORE II ≥4% or logistic EuroSCORE I ≥10% or other risk factors not included in these scores such as frailty, porcelain aorta, sequelae of chest radiation

b  Frailty: Poor mobility, as assessed by the 6-minute walk test, and oxygen dependency are the main factors associated with increased mortality after TAVI and other VHD treatments. The assessment of frailty should not rely on a subjective approach, such as the ‘eyeball test’, but rather on a combination of different objective estimates. 

References:

1

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. June 10, 2014;129(23):2440-2492.

2

Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. June 20, 2017;135(25):e1159-e1195.

3

Baumgartner, H., et al. (2017).2017 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal, Volume 38, Issue 36.21 September 2017. Pages 2739-2791. https://doi.org/10.1093/eurheartj/ehx391.

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