Aortic Stenosis Treatment: TAVR – How it is done
In this video from MedCram, Dr. Seheult discusses a procedure known as TAVR/TAVI or transcatheter aortic valve replacement/implantation.
Who is TAVR done on?
This procedure was initially used on elderly patients that could not tolerate the traditional surgery for aortic valve replacement. The results from the TAVR have turned out so well that it is now used regularly, and it is FDA approved for most patients. Essentially in this procedure, a catheter is introduced into the body through the arterial circulation into the area of the aortic valve. The catheter is then inserted through the aortic valve, and the catheter is deployed. It pushes the old valves out of the way and puts in a new valve. The new valves are bioprosthetic.
Is it FDA approved?
The data from the Partner 3 trial showed that the primary outcome of all-cause mortality, stroke, or rehospitalization in low-risk patients were reduced at 1 year with 8.5% in the TAVR group and 15.1% in the standard aortic valve replacement (SAVR) group. The conclusion was that the TAVR was superior to the SAVR among low risk patients with aortic stenosis and this is why it got FDA approval in 2019.
How to decide if you get a TAVR vs regular surgery?
Back in 2014, the decision as to whether to use a TAVR or not was based on the surgical risk. If it was high, then a TAVR was utilized. Today, surgical risk is still a factor; however, age is the key factor now such that if the patient is over the age of 80 or has a life expectancy of less than 10 years the TAVR is recommended. If the patient is between 65-80 years of age, then a discussion can be had as to whether to do a TAVR vs SAVR.
TAVR and anticoagulation
Due to the valve being bioprosthetic, anticoagulation is not necessarily mandatory; however, there are some recommendations because there are some in-valve stroke risks. There are two sets of guideless. The European ESC/EACTS 2021 Guidelines, state that for patients without underlying indication for chronic oral anticoagulants, they recommend an aspirin daily or clopidogrel daily for life. For patients with underlying indications for chronic oral anticoagulation, they recommend lifelong anticoagulation in those cases. For the American guidelines from the AHA/ACC 2020 guidelines, they are more complicated. For patients without underlying indications for chronic anticoagulation they recommend aspirin, but for those patients with low bleeding risk they also recommend dual antiplatelet therapy for 3-6 months after implantation or a vitamin K antagonist to achieve an INR of 2.5 for at least 3 months after valve implantation.
TAVR is becoming more popular and more patients can be found that have had this procedure done.
LINKS / REFERENCES:
Current Status of Transcatheter Aortic Valve Replacement (JACC) | https://www.jacc.org/doi/abs/10.1016/…
Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients (NEJM) | https://pubmed.ncbi.nlm.nih.gov/30883…
Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement (MDPI) | https://www.mdpi.com/2077-0383/11/8/2190