Transcatheter Aortic Valve Replacement Periprocedural Care

Updated: Dec 07, 2015
  • Author: Ramin Assadi, MD; Chief Editor: Eric H Yang, MD  more...
  • Print
Periprocedural Care

Patient Education & Consent

For obtaining informed consent, it is critical to appropriately inform patients and their family about the benefits and risks of the procedure so the patient is ultimately able to make a voluntary decision. A central goal in this interaction is the exchange of relevant detailed information about treatment strategies delivered in terminology that is understood by the patient and family. It is important to recognize that risk tolerance and patient expectations vary across many patient populations. Thus, a thorough review of personalized risk/benefit profile is essential for each patient undergoing transcatheter aortic valve replacement (TAVR).

Next:

Pre-Procedure Planning

Patients who are considered for TAVR should undergo the preprocedural workup below.

Echocardiography is used to confirm the severity of aortic stenosis, aortic valve anatomy, and extent of calcification and to evaluate the diameter of the aortic annulus, ascending aorta, sinus of Valsalva, the distance of the aortic valve leaflets to sinotubular junction, the presence of concomitant severe other valvular disease, and the LVEF.

CT angiography of the aortic root is used to determine the optimal image orientation for valve positioning.

Left and right cardiac catheterization is used to evaluate for concomitant coronary artery disease or pulmonary hypertension that may require treatment prior to TAVR.

CT angiography of the thoracoabdominal and iliofemoral arteries is used to evaluate the diameter, tortuosity of the vessels, and calcifications and to plan for the access site. [9, 22]

Previous
Next:

Equipment

The equipment required for TAVR depends on the specific approach to the procedure and the performing center protocols.

CoreValve

The current, third-generation 18F CoreValve System has 3 components, as follows:

  • A self-expanding nitinol support frame with cells configured in a diamond cell design, which anchors a trileaflet porcine pericardial tissue valve
  • An 18F delivery catheter
  • A disposable loading system
    Medtronic core valve Medtronic core valve

Edwards-SAPIEN valve

The Edwards SAPIEN valve is a trileaflet bioprosthesis made of bovine pericardium mounted on a balloon-expandable stainless-steel stent. This system is currently available in two sizes: (1) a 23-mm valve with a stent height of 14.3 mm and (2) a 26-mm valve with a stent height of 16.1 mm.

Edwards-Sapien valve Edwards-Sapien valve
Sizes and heights of available Edwards-Sapien valv Sizes and heights of available Edwards-Sapien valve systems

The second-generation device, Edwards SAPIEN XT, is made of a cobalt-chromium alloy, which provides the same radial strength with a reduced valve profile. This valve is currently commercially available in Europe and is approved for the TF approach. It is under investigation for the TA approach. The system will be available in 21-mm and 29-mm sizes in the future. [22]

Retroflex balloon catheter

The retroflex balloon catheter is used for valvuloplasty of the stenotic native aortic valve prior to implantation of an Edwards SAPIEN transcatheter heart valve. The device is not intended for postdilation of deployed transcatheter heart valves.

Crimper

The crimper is used in preparing the Edwards SAPIEN transcatheter heart valve for implantation by manually and symmetrically compressing the overall diameter of the bioprosthesis from its expanded size to its minimal delivery profile. The provided cylindrical gauge is used to confirm that the collapsed profile of the valve system will feasibly move through the introducer sheath. A measuring ring is used to calibrate the balloon inflation to its desired size and to determine the amount of saline/contrast mixture in the syringe required for balloon inflation at the time of deployment.

Retroflex guiding catheter

This catheter has a deflectable tip that changes direction when activated by the rotation of an actuator incorporated in the handle. The catheter is then used to direct the valve delivery system through the arterial system, around the aortic arch, and across the aortic valve, providing a less traumatic passage. The retroflex catheter assists in centering and supporting the valve as it crosses the calcified and stenotic native valve.

The Novoflex catheter is a newer-generation catheter that allows loading of the Edwards SAPIEN XT prosthesis onto the balloon while in the body, decreasing the sheath size dramatically.

Ascendra delivery system

This delivery catheter is used for the TA approach. The catheter allows for easy manipulation of the valve to improve orientation of the bioprosthesis.

Delivery sheath

This a 25-cm–long hydrophilic-coated sheath that is advanced into the abdominal aorta to decrease vascular complications, as the bioprosthetic valve and the deflecting guide catheter are introduced into the aorta. The sheaths are equipped with a hemostatic mechanism to decrease blood loss. The TF delivery system requires a 22F and 24F sheath for the 23-mm and 26-mm valves, respectively. See Table 3.

The TA sheath is 26F, is shorter, and has a flexible tip to minimize trauma as it is introduced in to the left ventricle. [9, 22, 25]

Previous
Next:

Patient Preparation

Anesthesia

Transcatheter aortic valve implantation can be performed under conscious sedation or general anesthesia. General anesthesia is preferred if TEE echocardiography is performed.

Positioning

The patient remains in the supine position during the procedure.

Testing and medications

Patients are pretreated with aspirin (81-325 mg) daily and clopidogrel 300-mg loading dose at least one hour prior to the procedure and continued at 81-mg oral daily dose. After the procedure, aspirin (at least 81 mg daily) is continued indefinitely, and clopidogrel 81 mg daily is continued for 1-6 months.

Adjunctive antacids are to be considered.

Routing laboratory tests prior to the procedure include complete blood cell (CBC) count, international normalized ratio (INR), partial thromboplastin time (PTT), albumin and transaminase levels, renal function testing, and 12-lead electrocardiography (ECG). Cardiac biomarker levels (ie, CK and CK-MB) are also tested within 48 hours of the procedure.

To minimize the risk of prosthetic valve infection, prophylactic intravenous antibiotic therapy at least 1 hour before the procedure is also recommended. The authors use cefuroxime 750 mg IV 1 hour preprocedure, and the dose is repeated 6 and 12 hours after the procedure. In patients who are allergic to penicillin (or cephalosporins), vancomycin may be considered.

Previous
Next:

Monitoring & Follow-up

The patient should be observed with a temporary pacemaker in a cardiovascular ICU for up to 48 hours to monitor for any conduction system abnormalities. If no conduction system disturbances are detected, the patient is monitored for an additional 72 hours and then discharged.

The patient should continue taking aspirin 81-325 mg daily and clopidogrel 75 mg daily for at least 3 months following the procedure.

Both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) may be used to guide the procedure and evaluate for complications, as needed.

Continuous invasive hemodynamic monitoring should be used throughout the procedure.

Previous
Next:

Operating Room

The procedure can be performed in the cardiac catheterization laboratory or in a hybrid operating room. A fixed fluoroscopy unit is required and should be capable of providing high-quality images, as well as storing the reference images. Cardiopulmonary bypass equipment should be available easily in case of complications. The room should also be equipped with supplies required to treat vascular and coronary complications.

Previous