Makindo Medical Notes

Related Subjects: |Aortic Anatomy |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Acute Heart Failure and Pulmonary Oedema |Aortic Regurgitation (Incompetence) |Aortic Stenosis |Aortic Sclerosis |Transcatheter aortic valve implantation (TAVI)

Prospective randomised data from the PARTNER B cohort has demonstrated that TAVI is superior to medical therapy in inoperable patients up to five years after valve implantation

About

• First TAVI done in 2004 on inoperable patient
• Consider in elderly patients with severe aortic stenosis and significant comorbidities.
• Avoids surgical trauma, cardiac arrest and cardiopulmonary bypass.
• Increasing older population

Criteria

• Symptomatic severe aortic stenosis
• Been turned down by a surgeon for surgical valve replacement
• Feasible access routes to implant the valve
• Been accepted after consideration by the TAVI MDT

Complications

• Mortality rate is 2 - 5%
• Stroke risk 2 - 3%
• Vascular complications 3 - 5%
• Pericardial tamponade
• Aortic rupture < 1 %
• Valve embolisation 1%
• Conversion to open heart surgery 1%
• Requirement for pacemaker post TAVI 15 - 40%

Procedure

• Antibiotics are required pre-procedure e.g. flucloxacillin 1 g IV and Gentamicin IV 120 mg followed by three further doses of flucloxacillin PO 500 mg at 6 hourly intervals
• The most common TAVI access route is trans-femoral, for which there needs to be a relatively disease free channel along the femorals, iliacs, and aorta, with femoral artery diameter at least 5 mm, sometimes more.
• Almost all patients will have had a CT aortogram (TAVI protocol) plus coronary +/- peripheral angiography.
• The majority of trans-femoral cases are done under local anaesthetic +/- sedation

Post op

• ECG monitoring is mandatory and patients need to be considered for permanent pacing if there is development of new LBBB (if associated bradycardia) or AV node block
• An echocardiogram is usually performed immediately after the procedure but sometimes needs to be repeated pre-discharge. Typical follow up is around 6-8 weeks after implant and then annually in the valve or general clinic
• Most patients will also have DAPT for 3 months (Aspirin 75 mg and Clopidogrel 75 mg) followed by Aspirin long term. If bleeding or there are intolerance concerns, Aspirin or Clopidogrel alone may be used

References

• TAVI 2018: from guidelines to practice