TAV-in-SAV procedural tips and tricks: patient selection

Transcatheter aortic valve implantation within failing surgical aortic bioprostheses

Patient selection plays a crucial role in the success of any procedure and has an equally important role in TAV-in-SAV. It requires meticulous attention to the smallest of details and needs to be performed in a systematic manner for every patient. In essence, the patient must be assessed from access to implantation site. Becoming over “complacent” and “routine” may lead to failure and impact patient safety.

What are the different steps in patient selection specifically for this procedure? Learn about the role of CT analysis in THV sizing and access route selection and why CT analysis is now recommended for all patients being considered for a TAV-in-SAV procedure. How does the routine use of transoesphageal echocardiography (TOE) in cases with predominant regurgitation exclude paravalvular leak? Learn more about these and other points in patient selection in this section.

The patient work-up for a TAV-in-SAV procedure should be extensive and thorough. Details of the initial surgical procedure should be sought and the indication for surgery, type and size of the surgical prosthesis documented. The bioprosthetic stenosis or regurgitation (or both) requires confirmation with echocardiography. However, it must be demonstrated that the bioprosthesis is indeed failing and stenotic, rather than there being a chronically elevated gradient due to a small surgical valve. Similarly, in cases of significant bioprosthesis incompetence, it is important to demonstrate that the aortic regurgitation is transvalvular rather than paravalvular. Ruling out active bioprosthetic infective endocarditis or valve thrombosis as failure mechanisms can also be achieved with echocardiography and laboratory testing. We advocate that all patients under consideration for TAV-in-SAV undergo CT analysis for the purposes of THV sizing and access route selection, and the routine use of transoesophageal echocardiography in cases with predominant regurgitation in order to exclude paravalvular leak.

Additional links

TAV-in-SAV: what “heart team” needs to know - by Niki Lama et al. ResearchGate Conference Paper March 2017 10.1594/ecr2017/C-1680

Pre-procedural imaging: patient selection - Imaging for transcatheter aortic valve therapy implantations

Valve-in-valve TAVI for the failing bioprosthesis - EuroPCR 2017 Session comprising selected abstracts