What is transcatheter aortic valve replacement (TAVI/TAVR)?
Transcatheter Aortic Valve Implantation (TAVI), also known as Transcatheter Aortic Valve Replacement (TAVR), is a revolutionary technique used to replace the aortic valve through a minimally invasive procedure.
This method is particularly suitable for patients with severe symptomatic aortic valve stenosis who are either not candidates for open-heart surgery or prefer a less invasive approach. The indication now includes all patients aged 75 years and older with this condition, as well as younger patients for whom surgical replacement is deemed high-risk.
Unlike surgical valve replacement, which involves a sternotomy/thoracotomy under general anesthesia and cardiopulmonary bypass, TAVI/TAVR involves the insertion of a new valve via a small catheter introduced through a tiny puncture, usually in the femoral region, with the patient typically awake under conscious sedation.
What are the advantages of TAVI/TAVR?
TAVI/TAVR offers several advantages over conventional surgical aortic valve replacement, including:
Minimally invasive approach: The procedure is performed through a small puncture and does not require opening the chest or using a heart-lung machine. This significantly reduces the risk of infections and major surgical complications such as arrhythmias, periprocedural myocardial infarction, major bleeding, and stroke.
Faster recovery after the procedure: Patients can mobilize within a few hours and are often discharged within 2 days, compared to the 1–2 weeks typically required for recovery following open-heart surgery. Furthermore, patients are transferred directly to the ward without the need for admission to the intensive care unit.
Reduced risk of complications: TAVI/TAVR has a lower complication rate compared to conventional open surgical aortic valve replacement.
Greater durability of the TAVI/TAVR bioprosthetic valve: Recent data suggest that due to the ability to place larger diameter bioprosthetic valves via TAVI/TAVR, their longevity appears to be superior to surgically implanted bioprosthetic valves.
What is the procedure of transcatheter aortic valve replacement (TAVI/TAVR)?
Before undergoing the TAVI/TAVR procedure, a specific preoperative work-up is required, which includes:
Blood tests: Complete blood count, urea, creatinine, potassium, sodium, SGOT, SGPT, γGT, total bilirubin, TSH, CRP, NT-proBNP, albumin, total proteins, blood group
Diagnostic coronary angiography
Carotid artery duplex ultrasound
TAVI computed tomography angiography (CTA): This study determines the size and type of the bioprosthetic valve and the access site
In cases of underlying pulmonary disease: pulmonary function tests (spirometry)
The TAVI procedure usually lasts 60–90 minutes and is performed under conscious sedation, without the need for general anesthesia. The procedure includes the following key steps:
Catheter insertion: A catheter carrying the new valve is introduced via a small puncture in the femoral region.
Temporary pacemaker insertion: A temporary pacing wire is inserted through the contralateral femoral vein to provide necessary pacing during valve deployment. The wire is removed either immediately or a few hours after the procedure.
Ultrasound-guided access: All vascular punctures are performed under ultrasound guidance to accurately locate the entry point and minimize vascular complications.
Valve deployment: The new valve is advanced to the site of the diseased valve and deployed via the catheter using fluoroscopic guidance and contrast agent.
Assessment and completion: After deployment, fluoroscopic and echocardiographic evaluation is performed to ensure proper valve function.
Are there complications associated with the TAVI/TAVR method?
As with any medical procedure, TAVI/TAVR carries certain risks and potential complications, though these are generally rare and significantly less frequent than with surgical valve replacement. The most common complications include:
Arrhythmias: Occur in <5% of patients and may require permanent pacemaker implantation.
Access site hematoma: Minor bleeding or hematoma at the femoral site occurs in <5% of cases.
Cardiac tamponade: Very rare; involves fluid accumulation around the heart (risk <1%).
Major bleeding: Rare; may require surgical or percutaneous intervention (<1%).
Acute kidney injury: Occurs in <0.5% of patients.
Stroke or myocardial infarction: Occur in <2% of patients.
Emergency percutaneous coronary intervention: May be required in <0.1% due to acute coronary artery obstruction after valve deployment.
Contrast allergy: Very rare (<0.04%).
Cardiac arrest or death: Rare (<1%).
What should be monitored postoperatively after the TAVI/TAVR procedure?
After TAVI/TAVR, patients typically recover much faster compared to traditional surgical aortic valve replacement. Mobilization occurs within a few hours following the procedure. Patients usually stay in the hospital for 48 hours post-procedure under telemetry (continuous ECG monitoring) and close observation to rule out serious conduction abnormalities requiring a pacemaker.
Additionally, the access site (femoral region) is regularly monitored for signs of bleeding or hematoma.
The day after the procedure, a transthoracic echocardiogram is performed to confirm proper valve function and assess overall cardiac performance.
The standard antithrombotic therapy post-implantation includes a low daily dose of aspirin.
Recovery is supported by a comprehensive cardiac rehabilitation program aimed at improving the patient’s overall functional status. Patients usually resume daily activities shortly after hospital discharge, while follow-up with the cardiologist continues regularly to ensure optimal valve and heart function.
Finally, one hour before any dental procedure, prophylactic antibiotic administration is necessary in accordance with the interventional cardiologist’s instructions.
What is the cost of the procedure?
The cost of transcatheter aortic valve replacement (TAVI/TAVR) varies depending on the clinic and the interventional cardiologist performing the procedure. The total cost includes the preoperative work-up and diagnostic testing, the TAVI/TAVR intervention itself, and hospitalization.
In conclusion, TAVI/TAVR is a highly safe and effective minimally invasive method for aortic valve replacement, offering substantial advantages such as restoration of normal cardiac function, improved prognosis, and significantly enhanced quality of life for patients with severe symptomatic aortic stenosis.
