Patient Selection for Transcatheter Aortic Valve

Patient Selection for Transcatheter Aortic Valve

Patient Selection for Transcatheter
Aortic Valve Implantation (TAVI)
Prof. Dr. Oktay Ergene
Atatürk Training and Research Hospital, Cardiology Department
Rapid Progression
After Being Symptomatic
30-40% of the patients with symptomatic
aortic stenosis are NOT treated !
Patient Selection Criteria
Within 45 days of the date of the procedure
Echocardiography: calcific aortic valve stenosis
mean gradient> 40 mmHg or jet velocity >4 m/s
AVA < 0.8 cm2 or AVAI < 0.5 cm2/m2
low EF Low gradient
dobutamine stres EKO
Normal EF low gradient
?
Symptomatic NYHA Class ≥ II
A cardiac interventionalist and experienced cardiothoracic surgeons
high risk for surgical AVR (STS score) or
medical factors preclude operation
JACC 2012
Echocardiographic Exclusion Criteria
• Congenital unicuspid or bicupid aortic valve or not
heavily calcified
• Mixed aortic valve disease (AS & dominant AI >3+).
• Severe mitral regurgitation (> 3+).
• Severe left ventricular dysfunction LVEF <20%
• Ascending aorta > 45 mm
• Hypertrophic cardiomyopathy w/ or w/o obstruction
• Severe pulmonary hypertension and RV dysfunction
• İntracardiac mass, thrombus or vegetation
• Subaortic stenosis
Evaluating the Patient for TAVI
• Assessment of the risk of the AVR
• Assessment of the aortic valve and the
aorta
• Access site assessment
• Coronary assessment
The risk of surgery
Cardiac & Extracardiac Factors
Risk Factors
not included in scoring systems
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Frailty
Porcelain aorta
Hepatic dysfunction
Right ventricular dysfunction
Previous sternotomy with multiple open
grafts
• Mediastinal irradiation
Frailty
Reversible physiologic phenotype?
Evaluating the Patient for TAVI
• Assessment of the risk of the AVR
• Assessment of the aortic valve and the
aorta
• Access site assessment
• Coronary assessment
Measurement of the aortic annulus
(TTE, TEE, MSCT, aortography)
Measurement of the aortic annulus
(TTE, TEE, MSCT, aortography)
Oval Annulus
Oval Annulus
Annulus measurement is critical
Edwards SAPIEN XT & Medtronic CoreValve
31 mm
26-29 mm
Measurement of the aortic annulus
(TTE, TEE, MSCT, aortography)
Measurement of the aortic annulus
(TTE, TEE, MSCT, aortography)
Measurement of the distance
between annulus & coronary ostium
(MSCT, aortography)
> 8 mm- >10 mm
Mean annulus- coronary ostium (LMCA) distance 13.4±3.2 mm
Mean annulus- coronary ostium (RCA) distance 13.6±2.8 mm
Edward SAPIEN XT & Medtronic
CoreValve
18 Fr
Evaluation of peripheral arteries
(MSCT, peripheral angiography)
> 6.5 mm
• Abdominal & thoracic
aortic aneursym > 5 cm
• Distinct tortiosity
• Atheroma on aortic
arch (>5 mm thick
ulcerated protruding )
Evaluation of peripheral arteries: Diameter
Evaluation of peripheral arteries: Diameter
Evaluation of peripheral arteries: Tortiosity
Evaluation of peripheral arteries: Calcification
Evaluation of peripheral arteries: Subclavian
Thank you for your attention