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Transcatheter Aortic Valve Implantation (TAVI)

Image by Robina Weermeijer

Transcatheter Aortic Valve Implantation (TAVI), also known as Transcatheter Aortic Valve Replacement (TAVR), is a minimally invasive procedure employed to replace a diseased aortic valve in patients with severe aortic stenosis who are deemed high-risk or unsuitable for traditional open-heart surgery. This intervention involves the percutaneous insertion of a bioprosthetic valve via a catheter, which is most commonly introduced through the femoral artery (transfemoral approach), although alternative access routes such as the subclavian artery, direct aortic, or transapical approaches may be utilized based on patient-specific anatomical considerations.

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The procedure begins with the positioning of a sheath in the chosen vascular access site (femoral artery or cut-down via subclavian artery), followed by the advancement of a guidewire across the stenotic native aortic valve under fluoroscopic and echocardiographic guidance. Pre-dilatation of the stenotic valve using balloon valvuloplasty may be performed to facilitate the passage and deployment of the transcatheter valve. The bioprosthetic valve, which is mounted on a balloon-expandable or self-expanding stent, is meticulously positioned across the native valve annulus. Upon accurate positioning, the valve is deployed, either by balloon inflation or by unsheathing the self-expanding stent, ensuring the new valve is securely anchored in place, thereby restoring competent valve function.

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Throughout the TAVI procedure, hemodynamic stability and valve positioning are monitored via real-time imaging modalities, including transesophageal echocardiography (TEE) and fluoroscopy. Post-deployment assessments ensure optimal valve function and the absence of complications such as paravalvular leak, valve malposition, or vascular injury.

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TAVI has revolutionized the management of aortic stenosis in high-risk surgical candidates by significantly reducing procedural morbidity and mortality, while providing symptomatic relief and improving the quality of life. The ongoing advancements in valve technology and procedural techniques continue to expand the indications for TAVI, encompassing a broader spectrum of patients with varying degrees of surgical risk.

A&I Protocol

  • Seldinger technique is used to access into the right common femoral artery using ultrasound guidance. Two Perclose devices are prepared on each puncture site (for closure at the end of the procedure). For a non-conventional approach (poor femoral artery access), a surigcal cut-down is performed by the cardiothoracic surgeon to gain access into the subclavian artery.

  • Seldinger technique is used to puncture the right common femoral vein to advance a pacing wire in the left ventricle (cardiac pacing at 180 to 200 bpm is an effective means to stabilize the balloon during aortic valvuloplasty and TAVI).

  • Seldinger technique is used to gain access into the right radial artery to deploy a cerebral protection device (Sentinel). This is deployed under fluoroscopic guidance.

  • A stiff 0.035" wire are advanced from the right common femoral artery.

  • The long, stiff wires are anchored in the aortic arch, and are checked using fluoroscopy of the thorax.

  • A calibrated pigtail catheter is advanced towards the aortic valve from the arterial access site (either right CFA or subclavian artery cut-down).

  • A pump injector run (cardiac cine mode >15 fps) is performed (e.g. 15mls at 15ml/sec) at the aorta. A frame showing contrast in the aortic valve is used as a reference image.

  • The TAVI device is prepared and advanced from the arterial access towards the aortic valve.

  • Once positioned in place, the TAVI device is partially deployed and another repeat pump injector run is performed to check the position.

  • The TAVI device is fully deployed after this position check.

  • Aortic balloon angioplasty is performed at the aortic valve.

  • A completion pump injector run is done to demonstrate the deployed TAVI device.

  • If an incomplete deployment is seen, additional aortic valve dilatation and post-dilatation angiogram are performed.

  • The radiographer changes the imaging mode from cardiac cine mode to DSA and a contrast injector run is performed at the CFA access site to check the integrity of the arteries post-TAVI. Not performed for the cut-down site.

  • The cerebral protection device is also removed.

  • Access sites are closed with closure devices and any cut-down sites are surgically closed.

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Pre-intervention of the aortic valve without the implant.

Post-intervention angiogram and post-aortic dilation showing the TAVI device positioned in the aortic valve.

References

  1. Dąbrowski M, Finkelstein A, Witkowski A. Transcatheter aortic valve implantation. Kardiol Pol. 2017;75(9):837–44. 

  2. Ponte Monteiro J, Brugaletta S, Freixa X, Regueiro A, Rijo D, Sabaté M. The roadmap to transcatheter aortic valve implantation. Rev Port Cardiol. 2023 Aug;42(8):733–9. 

  3. Mack MJ, Leon MB, Thourani VH, Pibarot P, Hahn RT, Genereux P, et al. Transcatheter Aortic-Valve Replacement in Low-Risk Patients at Five Years. N Engl J Med. 2023 Nov 23;389(21):1949–60.

  4. Mack MJ, Leon MB, Thourani VH, Pibarot P, Hahn RT, Genereux P, et al. Transcatheter Aortic-Valve Replacement in Low-Risk Patients at Five Years. N Engl J Med. 2023 Nov 23;389(21):1949–60. 

  5. Bové T. Transcatheter Aortic Valve Implantation: Transvascular Is the Way to Go! Am J Cardiol. 2023 Aug 15;201:308–9.

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