Transcatheter aortic valve implantation for aortic stenosis: Periprocedural and postprocedural management

INTRODUCTION — 

Aortic valve replacement is the mainstay of treatment of symptomatic severe aortic stenosis (AS). The role of transcatheter aortic valve implantation (TAVI; also known as transcatheter aortic valve replacement or TAVR) is an established alternative to surgical aortic valve replacement (SAVR) with the number of TAVIs first exceeding the number of SAVRs in the United States in 2019 [1]. (See "Choice of intervention for severe calcific aortic stenosis".)

This topic will review periprocedural management of TAVI.

Related issues are discussed separately:

●(See "High-gradient aortic stenosis in adults: Indications for valve replacement" and "Low gradient severe aortic stenosis: Management and prognosis" and "Choice of intervention for severe calcific aortic stenosis" and "Estimating the risk of valvular procedures".)

●(See "Transcatheter aortic valve implantation: Antithrombotic therapy".)

●(See "Medical management of symptomatic aortic stenosis".)

●(See "Percutaneous balloon aortic valvotomy for native aortic stenosis in adults".)

PREPROCEDURAL CONSIDERATIONS

Heart Valve Team — Patients with severe AS should be referred to a multidisciplinary Heart Valve Team for evaluation and management [2-4]. This team should comprise interventional and noninterventional cardiologists with training and expertise in valvular heart disease (including the primary clinical cardiologist and an echocardiographic imaging specialist), a specialist in advanced cardiovascular imaging (including cardiac computed tomography of the aortic valve), a cardiac surgeon with expertise in treatment of valve disease, and may include other clinicians with relevant expertise, including a cardiovascular anesthesiologist, critical care and pulmonary specialists involved in periprocedural care, and cardiovascular nurses.

Preprocedural assessment — Preprocedural testing should include:

●Routine blood tests (including complete blood count, prothrombin time, activated partial thromboplastin time, electrolytes, blood urea nitrogen, and serum creatinine).

●An electrocardiogram.

●Resting echocardiography (transthoracic and, in some cases, transesophageal) to stage AS (table 1).

If low-gradient AS is suspected, low-dose dobutamine stress echocardiography and/or computed tomography may also be indicated, as discussed separately. (See "Low gradient severe aortic stenosis: Clinical manifestations and diagnosis", section on 'Additional evaluation based upon type of low gradient AS'.)

●Comprehensive cardiac computed tomography to assess aortic annulus geometry and peripheral access. (See "Imaging for transcatheter aortic valve implantation".)

Preprocedural evaluation — The following issues should be reviewed and discussed by the Heart Valve Team:

●Indication for aortic valve intervention – Determination of whether aortic valve intervention (TAVI or SAVR) is indicated based upon the patient's clinical presentation, stage of AS (table 1), and concurrent conditions. (See "High-gradient aortic stenosis in adults: Indications for valve replacement" and "Low gradient severe aortic stenosis: Management and prognosis", section on 'Choice of therapy'.)

●Choice of aortic valve intervention – Among patients with an indication for aortic valve intervention, the choice of therapy (SAVR, TAVI, or medical management) is based upon potential risks (including absolute and relative contraindications for SAVR or TAVI) and benefits of treatment options. These issues are discussed further separately. (See "High-gradient aortic stenosis in adults: Indications for valve replacement" and "Choice of intervention for severe calcific aortic stenosis".)

•Risk factors, such as depressed left ventricular ejection fraction (LVEF), and concurrent conditions such as coronary artery disease (CAD), kidney disease, prior stroke, and respiratory disorders should be considered. (See 'Management of coronary artery disease' below and 'Management of comorbid conditions' below.)

•TAVI access issues and likely delivery approach should be discussed, since the access route may impact the risk-benefit analysis of treatment options. (See 'Access routes' below.)

Preprocedural management — Preprocedural management includes selection of the optimal clinical setting for the procedure, management of concurrent CAD if present, and management of chronic oral anticoagulant therapy.

Clinical setting — The choice of the optimal clinical setting for the procedure is based upon regional clinical expertise and experience, as well as patient access. Observational data suggest that patients with AS undergoing TAVI or SAVR have better outcomes when managed at experienced centers with high case volumes of both TAVI and SAVR [5].

An inverse relationship between hospital TAVI procedural volume and mortality has been observed [6]. In an analysis of data from the Transcatheter Valve Therapy Registry on 96,256 transfemoral TAVI procedures during 2015 to 2017 at 554 hospitals, adjusted 30-day mortality was higher and more variable in hospitals in the lowest volume quartile (mean annualized volume of 27 procedures; mortality 3.19 percent, 95% CI 2.78-3.67) than at hospitals in the highest volume quartile (mean annualized volume of 143 procedures; mortality 2.66 percent, 95% CI 2.48-2.85; odds ratio [OR] 1.21, 95% CI 1.03-1.41). An analysis of 8644 nontransfemoral TAVI cases at 486 sites also revealed an inverse relationship between volume of TAVI procedures and mortality, with adjusted 30-day mortality of 10.13 percent in the lowest-volume quartile and 6.40 percent in the highest volume quartile (OR 1.65, 95% CI 1.20-2.27).

An analysis of data from the 2019 Nationwide Readmission Database classified hospitals as high (≥50^th percentile) or low (<50^th percentile) volume centers [5]. In-hospital mortality and 30-day readmission rates after total aortic valve replacement (TAVI or SAVR) were assessed in 72,123 patients at 400 US hospitals. Median hospital procedure volumes were 82 for TAVI, 56 for SAVR, and 137 for both procedures. Compared with high TAVI/high SAVR volume hospitals, there was higher in-hospital mortality after total aortic valve replacement among low TAVI/low SAVR volume hospitals (adjusted OR 1.29, 95% CI 1.07-1.56). In-hospital mortality was similar after total aortic valve replacement for high TAVI/low SAVR and low TAVI/high SAVR volume hospitals. Thirty-day readmission rates after aortic valve intervention was similar among the four hospital procedure volume categories.

Management of coronary artery disease — Invasive coronary angiography is routinely performed prior to TAVI to assess for concurrent CAD.

Patients with low pretest probability for CAD (eg, selected younger patients without angina or dyspnea) may be evaluated by coronary computed tomographic angiography as a screening procedure to assess the need for invasive coronary angiography [2,7].

Patients undergoing TAVI commonly have chronic CAD and may be candidates for percutaneous coronary intervention (PCI) to reduce the risk of myocardial infarction and need for urgent revascularization. On the other hand, if coronary artery bypass graft (CABG) is deemed necessary to treat the patient's CAD, then SAVR is generally preferred to TAVI. (See "Choice of intervention for severe calcific aortic stenosis", section on 'Contraindications to TAVI'.)

Outcomes with TAVI with or without PCI were assessed by a trial which enrolled 455 patients (mean age 82 years) with chronic CAD undergoing TAVI. The participants were randomly assigned to PCI (performed in most cases as a staged procedure prior to TAVI) or conservative management of CAD [8]. Patients with left main coronary artery stenosis were excluded. Patients undergoing PCI received standard dual antiplatelet therapy after the procedure.

●PCI reduced the two-year risk of myocardial infarction (7 versus 14 percent; hazard ratio [HR] 0.54, 95% CI 0.30-0.97) and urgent coronary revascularization (2 versus 11 percent; HR 0.20, 95% CI 0.08-0.51). Rates of acute kidney failure were also lower with PCI (5 versus 11 percent; HR 0.45, 95% CI 0.23-0.89).

●At median follow-up of two years, rates of death from any cause (23 versus 27 percent; HR 0.85, 95% CI 0.59-1.23) and stroke (23 versus 35 percent; HR 0.67, 95% CI 0.39-1.14) were similar with PCI versus conservative management. A composite endpoint (comprising death from any cause, myocardial infarction, or urgent revascularization ) occurred in fewer patients in the PCI group compared with the conservative management group (26 versus 36 percent; HR 0.71, 95% CI 0.51 to 0.99). Bleeding rates were higher with PCI (28 versus 20 percent; HR 1.51, 95% CI 1.03-2.22).

Management of chronic anticoagulant — Many patients undergoing TAVI have an indication for chronic oral anticoagulation due to a concomitant condition (most commonly atrial fibrillation).

●For most patients taking a chronic oral anticoagulant (eg, for atrial fibrillation) – For most patients undergoing TAVI who have an indication for chronic anticoagulation, the oral anticoagulant is stopped before the procedure (eg, 48 hours prior for most patients receiving a direct oral anticoagulant) and restarted as soon as deemed safe after the procedure, although practice varies. In general, there is no need for heparin bridging.

Support for an approach of brief perioperative interruption of oral anticoagulant therapy for patients with atrial fibrillation comes from an open-label randomized trial in 858 patients receiving oral anticoagulants (direct oral anticoagulant or warfarin; nearly all patients had atrial fibrillation) and planning to undergo TAVI found that patients continuing oral anticoagulant and those interrupting oral anticoagulant (without heparin bridging) during TAVI had similar rates of a composite outcome of death from cardiovascular causes, stroke, myocardial infarction, major vascular complications, or major bleeding at 30 days (16.4 versus 14.8 percent; risk difference 1.7 percentage points, 95% CI -3.1 to 6.6) [9].

•Thromboembolic events occurred at similar rates in the continuation group and interruption group (8.8 and 8.2 percent; risk difference 0.6 percentage points, 95% CI -3.1 to 4.4). Stroke rates were also similar in the two groups 14 (3.2 versus 4.4 percent; risk difference -1.2 percentage points, 95% CI -3.8 to 1.4).

•Bleeding was more frequent in the continuation group than in the interruption group (31.1 versus 21.3 percent; risk difference 9.8 percentage points, 95% CI 3.9-15.6), although major bleeding rates were similar (11.1 versus 8.9 percent; risk difference 2.2 percentage points, 95% CI -1.8 to 6.3).

●For patients with a mechanical valve – For the rare clinical scenario of patients with a mechanical valve (eg, mitral) who are undergoing TAVI [10], the management of oral anticoagulation (vitamin K antagonist) is discussed separately. (See "Anticoagulation for prosthetic heart valves: Management of bleeding and invasive procedures".)

PROCEDURAL CONSIDERATIONS — 

TAVI procedural management includes administration of antimicrobial prophylaxis, monitoring, anticoagulation with heparin during the procedure, temporary pacemaker lead placement (use varies), access (transfemoral or an alternative approach), anesthesia technique selection and care, hemodynamic management, and prevention and treatment of complications. (See "Transcatheter aortic valve implantation: Complications".)

Procedural antibiotic prophylaxis — Routine antibiotic prophylaxis is recommended for all patients undergoing TAVI prior to surgical incision or vascular access to reduce the risk of wound infection and endocarditis using the same protocols used for cardiac surgery (table 2) [11]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Cardiac surgery'.)

Monitoring and pacing — Patients undergoing TAVI generally receive at least one large-bore intravenous line, warming to avoid hypothermia if general anesthesia is used, and monitoring by arterial line [11]. A pulmonary artery catheter is seldom used during the procedure. Transesophageal echocardiography is commonly performed when general anesthesia is used.

A temporary pacing lead is commonly placed, but use varies widely, and an increasingly common practice is to pace with the preshaped LV TAVI wire.

Procedural anticoagulation — Intravenous unfractionated heparin (weight-adjusted with target activated clotting time between 250 and 300 seconds) is administered after placement of standard sheaths and prior to placement of the large sheath.

At the conclusion of the procedure, after arterial sheath removal, protamine is routinely administered for heparin reversal. An observational study of 873 patients undergoing TAVI, of whom 677 received protamine, found that protamine administration was associated with reduced rates of life-threatening and major bleeding complications with no increase in the risk of stroke [12].

Access routes

Choice of access route — Preprocedural assessment for TAVI includes assessment of the iliofemoral system and aorta, generally by multidetector computed tomography with optional invasive angiography to detect contraindications to vascular (transfemoral, subclavian, or aortic) access such as plaques with mobile thrombi in the ascending aorta or arch, inadequate vessel size, extensive calcification, or tortuosity. (See "Imaging for transcatheter aortic valve implantation", section on 'Determining eligibility for peripheral vascular access'.)

Several types of stent-valve devices with various designs have been successfully implanted using the retrograde femoral approach. The most widely used types are balloon-expandable valves (SAPIEN 3 and SAPIEN 3 Ultra, which have replaced the Cribier-Edwards, SAPIEN, and SAPIEN XT valves) and self-expanding valves (eg, Evolut PRO/PRO-PLUS, ACURATE neo, and Portico) [13]. The SAPIEN 3 and SAPIEN 3 Ultra valves can also be delivered via the transapical or direct aortic approach as described below. The Evolut PRO/PRO-PLUS can also been delivered in a retrograde fashion from the subclavian/axillary artery [14], the carotid artery, and via direct aortic access via either ministernotomy or right anterior thoracotomy [15].

Transfemoral approach — The percutaneous retrograde femoral arterial approach via the aortic arch and through the diseased valve is the most common and favored approach to TAVI delivery, since there is greater experience and superior outcomes with transfemoral access. Nearly all (>95 percent) TAVI cases can be performed via this route, reflecting smaller sheath sizes in newer-generation devices (14 to 16 F equivalent). Smaller delivery devices have also reduced the risk of vascular complications, with standard use of a percutaneous vascular closure device and shorter hospital stays.

Contraindications to the transfemoral approach include extreme femoral vessel tortuosity or vessel size of less than 5 mm with circumferential calcium. For patients with calcific iliofemoral vessels, transfemoral access may be facilitated by peripheral lithotripsy [16].

The benefits of TAVI over surgery in the PARTNER 2 trial and United States Pivotal Trial were greatest in the transfemoral cohorts. However, it is unclear how much of the excess mortality seen in patients undergoing alternative access TAVI was caused by the alternative access procedure per se (and associated need for general anesthesia (see 'Anesthetic management' below)) and how much is caused by excess risk associated with the burden of greater atherosclerotic arterial disease mandating the need for alternative access and associated comorbidities [17]. (See "Choice of intervention for severe calcific aortic stenosis", section on 'By access site'.)

Alternative approaches — For patients who are not candidates for the transfemoral approach due to unfavorable iliofemoral artery characteristics, the choice of alternative access route is based upon patient-specific anatomy and risk factors, the type of valve delivery system used, and operator and institutional practice and experience.

Extrathoracic access is associated with lower morbidity and mortality than intrathoracic access and is therefore generally preferred over intrathoracic access [17]. Support for this approach comes from a meta-analysis which included 18 studies with 5032 patients undergoing extrathoracic access TAVI and 6800 patients undergoing intrathoracic access TAVI [18]:

●Patients treated with intrathoracic access had higher risk of in-hospital or 30 day mortality (relative risk [RR] 1.99, 95% CI 1.67-2.36) as well as higher risk of one-year mortality (RR 1.31, 95% CI 1.21-1.42). Patients treated with intrathoracic access also had higher risks of postoperative life-threatening bleeding, 30-day new-onset atrial fibrillation or flutter, 30-day acute kidney injury requiring kidney replacement therapy, and discharge to a care facility.

●On the other hand, the risks of postoperative permanent pacemaker implantation and significant paravavular leak were lower with intrathoracic access. Stroke rates were similar with intrathoracic and extrathoracic access.

●However, this analysis was limited to observational studies since randomized controlled data are not available, and the potential role of differing baseline characteristics and comorbidities was not assessed.

Features of various alternative access approaches are reviewed below.

Extrathoracic access — Extrathoracic access includes transcarotid, transcaval, transaxillary, and subclavian approaches.

•Transcarotid – The transcarotid approach is a convenient extrathoracic location and is the most commonly used nonfemoral access site in North America. The transcarotid retrograde approach is performed by surgical cut-down of the common carotid artery for insertion of the transcatheter heart valve (THV) delivery system.

To support cerebral perfusion, the systolic blood pressure should be maintained >140 mmHg [17]. Despite early concerns of stroke risk, in contemporary practice, the stroke risk with the transcarotid approach is similar to or lower than the stroke risk with other nonfemoral access sites [17].

•Transcaval – The transcaval approach involves passage of an electrified guidewire from the inferior vena cava toward a snare in the abdominal aorta [19]. The THV introducer sheath is advanced from the femoral vein into the abdominal aorta for retrograde TAVI. This creates a generally tolerated transient aortocaval fistula. Advantages of this approach include lower radiation exposure than other alternate access techniques and relatively low risk of iatrogenic stroke, similar to transfemoral access [17].

Angiography is performed after the procedure to assess for residual aortocaval fistula or hemorrhage. Aortic hemorrhage is treated with tamponade with a low-pressure oversized compliant balloon. Covered-stent implantation is indicated to treat persistent hemorrhage or rare cases of persistent fistula shunt flow that is not tolerated [17].

•Transaxillary – Advantages of the transaxillary approach are its extrathoracic location and relative ease of percutaneous or via surgical access [17]. However, the approach may be associated with elevated risk of stroke (eg, 6.1 percent in one series [20]) and is also associated with risk of brachial plexus injury.

•Subclavian – The transaxillary approach differs from uncommon supraclavicular access via the true subclavian artery by surgical exposure but may be difficult to distinguish from transaxillary access in large data sets [17].

Intrathoracic access — Intrathoracic access routes (transaortic and transapical) are considered when extrathoracic access is not feasible.

•Transaortic – The transaortic retrograde surgical approach is performed by direct insertion of the THV delivery system into the ascending aorta (eg, aortotomy) using a sheath placed into the aorta via a small median sternotomy or lateral thoracotomy at the second intercostal space. Extensive ascending aortic calcification is an infrequent contraindication to the direct aortic approach, as a soft spot for catheter entry can usually be found.

•Transapical – The transapical antegrade approach involves direct LV apical puncture for insertion of the THV delivery system and antegrade aortic valve implantation via a small anterolateral thoracotomy without cardiopulmonary bypass or sternotomy. This approach is particularly suited to patients with severe peripheral artery disease and heavily calcified ascending aorta and arch (porcelain aorta) who have an increased risk of stroke and other embolic events using other approaches. However conditions such as severe pulmonary disease and LV apical thrombus are contraindications.

Anesthetic management — Selection of anesthesia technique varies depending upon the TAVI access route and center and operator practice:

●Transfemoral or transcaval TAVI may be performed with either local anesthesia with moderate (conscious) sedation or general anesthesia.

●Patients requiring a axillary or subclavian approach commonly receive general anesthesia, although there is increasing use of local anesthesia with moderate sedation.

●Patients requiring a transaortic, transapical, or transcarotid approach generally receive general anesthesia.

As center and operator experience has grown, there has been a move toward performing TAVI with a less invasive approach [21]. While practice varies considerably, this approach encompasses performing the procedure under conscious sedation with local anesthesia, without transesophageal echocardiography, and with selective use of temporary pacing (including using the preshaped LV wire for this purpose). Some operators have moved away from having any anesthesia support and most have dispensed with central venous access. Anesthetic management (including discussion of studies comparing anesthetic approaches) is discussed further separately. (See "Anesthesia for percutaneous cardiac valve interventions", section on 'Transcatheter aortic valve implantation'.)

Implantation procedure — Prior to the implantation, the available imaging of the aortic root (including preprocedural computed tomography angiography and echocardiography) should be displayed for the operators.

The implantation procedure consists of five phases:

●The first is to obtain vascular access for delivery of the valve. (See 'Access routes' above.)

●Second, the operators use the available aortic root imaging to establish a clear coplanar view of the aortic annulus. The standard coplanar view has all three aortic cusps equidistant and aligned. However, for self-expanding valves, there is increasing use of the "cusp overlap" view, which isolates the noncoronary cusp (right and left coronary cusps overlap) and elongates the LV outflow tract. This information is used to guide THV size and placement. (See "Imaging for transcatheter aortic valve implantation".)

●In selected cases, a balloon aortic valvuloplasty is performed prior to delivery of the THV [22]. Indications for predilation include the presence of one or more of the following: bicuspid aortic valve, very heavy valve calcification, difficulty crossing the valve, or extremely high transvalvular gradient. (See "Percutaneous balloon aortic valvotomy for native aortic stenosis in adults", section on 'Indications for percutaneous balloon aortic valvotomy'.)

●Next, the THV is delivered. The range of implantation techniques and methods varies widely, as valve design and methods of expansion mandate different delivery approaches, although some principles are universal:

•The valve should be correctly positioned in the aortic annulus, extending below the plane of the annulus by between 2 and 5 mm, depending upon the valve design. It should be positioned to avoid paravalvular leaks and coronary occlusion.

•Its position should be checked with fluoroscopy and possibly echocardiography as well.

Any paravalvular leak that is present should be quantified with a combination of echocardiography, angiography, and pressure measurement to calculate the aortic regurgitation index. The aortic regurgitation index is

in which DBP is aortic diastolic blood pressure, LVEDP is LV end-diastolic pressure, and SBP is systolic blood pressure.

●If there is an indication for repositioning (such as suboptimal depth or angulation of the initial implantation, paravalvular regurgitation, new or worsened atrioventricular block, or coronary artery impingement), and the valve is of a recapturable and repositionable type, then repositioning should be considered. Finally, the need for a postdeployment valvuloplasty should be considered to improve frame expansion if this is a concern.

Hemodynamic management — All procedures require early identification and treatment of volume depletion, low cardiac output, and greater than moderate pulmonary hypertension.

●Measures to avoid prolonged hypotension include maintenance of mean arterial pressure >75 mmHg prior to initiation of rapid ventricular pacing, with cautious use of intravenous vasopressor (metaraminol, norepinephrine, epinephrine, or phenylephrine) therapy as needed while avoiding hypertension.

●Treatment of low cardiac output – Patients with low cardiac output undergoing TAVI may require an intravenous inotrope (eg, metaraminol, norepinephrine), but mechanical circulatory support is very rarely required. (See "Short-term mechanical circulatory assist devices" and "Anesthesia for percutaneous cardiac valve interventions", section on 'Transcatheter aortic valve implantation'.)

No established role for cerebral embolic protection — Cerebral embolic protection (CEP) systems have been developed to capture or deflect debris released during TAVI to reduce the risk of stroke. However, a clinical benefit from CEP systems has not been established.

A meta-analysis of seven randomized trials included 2171 patients in the CEP group (using one of four different systems) and 1860 in the control group [23]. Stroke rates were similar in the groups with and without CEP (odds ratio [OR] 0.84, 95% CI 0.60-1.17). Mortality rates were similar in CEP and control groups (OR 1.04, 95% CI 0.50-2.18).

A subsequent multicenter trial randomly assigned 7635 participants with AS at 33 centers to TAVI with a CEP device or TAVI without a CEP device (control group) [24]. Stroke within 72 hours after TAVI or before earlier hospital discharge occurred in 2.1 percent of the CEP group participants and 2.2 percent of the control group participants (difference -0.02 percentage points, 95% CI -0.68 to 0.63). Disabling stroke rates (1.2 versus 1.4 percent) and mortality rates (0.8 versus 0.7 percent) were also similar in the two groups. Access-site complications (8.1 versus 7.7 percent) were similar in the two groups. Serious adverse events occurred in 0.6 percent in the CEP group and 0.3 percent in the control group.

The risk of stroke after TAVI is discussed further separately. (See "Transcatheter aortic valve implantation: Complications", section on 'Stroke and subclinical brain injury'.)

Complications — Management of complications of TAVI is discussed separately. (See "Transcatheter aortic valve implantation: Complications".)

POSTPROCEDURAL CARE

Follow-up

●Routine follow-up – Care post-TAVI includes clinical and echocardiographic follow-up of transcatheter bioprosthetic valve function, including assessment of the transvalvular gradient and surveillance for complications. Patients typically undergo routine clinical evaluation including echocardiography prior to discharge and at one-month follow-up, at 6 to 12 months, and then annually.

●Complications – More frequent follow-up is required for complications such as paravalvular regurgitation and associated conditions such as heart failure (HF). Complications of TAVI are discussed separately. (See "Transcatheter aortic valve implantation: Complications".)

Antithrombotic therapy — Post-TAVI antithrombotic therapy is discussed separately. (See "Transcatheter aortic valve implantation: Antithrombotic therapy".)

Endocarditis prophylaxis — All patients with prosthetic valves, including those who have undergone TAVI, are considered among those at highest risk for endocarditis. (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

●Patient education – In this setting, patients should be provided instruction regarding the risk of infective endocarditis, the importance of optimal dental hygiene and regular dental care, the need for endocarditis prophylaxis at the time of relevant procedures, and the importance of seeking prompt medical attention (including blood cultures) if symptoms of endocarditis develop or if they develop an infection that may cause endocarditis. (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures", section on 'Maintenance of oral hygiene'.)

●Antimicrobial prophylaxis – This is recommended in the setting of relevant procedures likely to result in bacteremia with a microorganism that is known to be a cause of endocarditis (eg, dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the oral mucosa, such as tooth extraction and routine dental cleaning). Relevant procedures and recommended regimens are discussed in detail separately. (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures", section on 'Antibiotic prophylaxis prior to invasive dental or oral procedures' and "Prevention of endocarditis: Antibiotic prophylaxis and other measures", section on 'Additional preventive measures'.)

Management of comorbid conditions — Patients undergoing TAVI commonly have one or more comorbid conditions that require ongoing follow-up and treatment and impact the risk of hospitalization [25,26]. These conditions are managed according to standard evidence-based recommendations. Common comorbid conditions include:

●Hypertension (observed in approximately 90 percent of patients [27]). (See "Overview of hypertension in adults" and "Hypertension in adults: Initial drug therapy".)

●CAD. (See "Chronic coronary syndrome: Overview of care".)

●HF, including:

•HF with preserved ejection fraction (HFpEF). (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Initial therapy (SGLT2 inhibitor)'.)

•HF with reduced ejection fraction (HFrEF). (See "Primary pharmacologic therapy for heart failure with reduced ejection fraction", section on 'Sodium-glucose co-transporter 2 inhibitors'.).

●Chronic kidney disease. (See "Overview of the management of chronic kidney disease in adults".)

●Chronic obstructive pulmonary disease. (See "COPD exacerbations: Management".)

●Type 2 diabetes mellitus. (See "Initial management of hyperglycemia in adults with type 2 diabetes mellitus" and "Management of persistent hyperglycemia in type 2 diabetes mellitus".)

●Atrial fibrillation. (See "Atrial fibrillation: Overview and management of new-onset atrial fibrillation".)

The following studies underscore the importance of treatment of comorbid conditions in patients who have undergone TAVI:

Treatment with a sodium-glucose cotransporter 2 (SGLT2) inhibitor is a component of evidence-based therapy for a number of conditions commonly occurring in patients undergoing TAVI (including those with HFrEF, HFpEF, and selected patients with type 2 diabetes mellitus and/or chronic kidney disease). The efficacy of SGLT2 inhibitor therapy post-TAVI was evaluated by a multicenter open-label randomized trial that enrolled patients after TAVI with history of HF plus one or more of the following conditions: moderate kidney disease (estimated glomerular filtration rate [eGFR] 25 to 75 mL/min per 1.73 m²), diabetes mellitus, or an LVEF ≤40 percent [28].

The 1257 trial participants were randomly assigned to receive dapagliflozin 10 mg daily plus standard care or standard care only. Many of the patients (44 percent) had type 2 diabetes mellitus and most (89 percent) had an eGFR value of 25 to 75 mL/min per 1.73 m².

●At one-year, all-cause mortality was similar in the two groups (7.8 versus 8.9 percent; hazard ratio [HR] 0.87, 95% CI 0.59-1.28). Worsening HF (defined as hospitalization or an urgent visit) was less common in the dapagliflozin group (9.4 versus 14.4 percent; subhazard ratio 0.63, 95% CI 0.45-0.88).

●There were higher rates of genital infection (1.8 versus 0.5 percent) and hypotension (6.6 versus 3.6 percent) in the dapagliflozin group.

All, or nearly all, of the trial participants had one or more conditions with an established indication for SGLT2 inhibitor therapy, so these findings do not establish a new indication for SGLT2 inhibition.

Similarly, patients undergoing TAVI commonly have one or more indications for renin-angiotensin system (RAS) inhibition, including hypertension, diabetes mellitus, chronic kidney disease, prior myocardial infarction, and HFrEF. Observational studies have identified lower mortality rates in patients (many with standard indications for RAS inhibition) who have undergone TAVI who are treated with a RAS inhibitor (angiotensin-converting enzyme [ACE] inhibitor or angiotensin II receptor blocker) compared with patients who have not received such therapy [29-34].

The effect of ACE inhibitor therapy post-TAVI was studied in a multicenter randomized open-label trial enrolling 186 adults (median age 83 years; most with a standard indication for RAS inhibition) with LVEF >40 percent (median 60 percent) who had undergone successful TAVI for AS [29]. Participants were randomly assigned to treatment with the ACE inhibitor ramipril or standard care. Patients with hypertension in the standard care group were treated with a non-RAS antagonist medication. At one-year follow-up, cardiac mortality was similar in the ramipril and control groups (1.1 versus 2.2 percent; HR 0.46, 95% CI 0.04-5.09) but the rate of HF readmissions was lower in the ramipril group (3.2 versus 10.9 percent; HR 0.27, 95% CI 0.08-0.99).

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cardiac valve disease" and "Society guideline links: Transcatheter aortic valve implantation".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword(s) of interest.)

Basics topics (See "Patient education: Transcatheter aortic valve implantation (The Basics)" and "Patient education: Transcatheter aortic valve implantation – Discharge instructions (The Basics)".)

SUMMARY AND RECOMMENDATIONS

●Preprocedural evaluation – Potential candidates for transcatheter aortic valve implantation (TAVI) should be fully evaluated by a multidisciplinary Heart Valve Team to assess the indication for and choice of aortic valve intervention (surgical aortic valve replacement [SAVR], TAVI, or medical management) including assessment of the clinical presentation, stage of aortic stenosis (AS) (table 1) and concurrent conditions (such as coronary artery disease [CAD]), as well as TAVI access issues. (See 'Preprocedural considerations' above and "High-gradient aortic stenosis in adults: Indications for valve replacement" and "Low gradient severe aortic stenosis: Management and prognosis" and "Choice of intervention for severe calcific aortic stenosis".)

●Preprocedural management – Preprocedural management includes selection of the optimal clinical setting for the procedure, management of concurrent CAD if present, and management of chronic oral anticoagulant therapy.

●Procedural considerations – TAVI procedural management includes administration of routine antimicrobial prophylaxis (table 2), monitoring, anticoagulation with heparin, access (transfemoral or an alternative approach), temporary pacemaker lead placement (use varies), anesthesia technique selection and management, hemodynamic management, and management of complications. (See 'Procedural considerations' above and "Anesthesia for percutaneous cardiac valve interventions", section on 'Transcatheter aortic valve implantation' and "Transcatheter aortic valve implantation: Complications".)

●Access routes – The transfemoral arterial approach is the most common and most favored method of TAVI delivery, and nearly all (>95 percent) cases can be performed via this route. For patients who are not candidates for the transfemoral approach due to unfavorable iliofemoral artery characteristics, the most common alternatives are the transcarotid approach, the transaxillary/subclavian approach, the transcaval approach, and two transthoracic approaches (transaortic and transapical). (See 'Access routes' above.)

●Implantation procedure – The transcatheter valve implantation procedure involves obtaining vascular access, establishing a clear coplanar view of the aortic annulus, balloon aortic valvuloplasty (in selected cases), delivery of the transcatheter heart valve (THV), repositioning (if indicated and feasible), and postdeployment valvuloplasty (if indicated to improve frame expansion). (See 'Implantation procedure' above.)

●Postprocedural care

•For all patients – Care for all patients post-TAVI includes:

-Follow-up – This includes routine clinical and echocardiographic monitoring and assessment for complications. (See 'Follow-up' above.)

-Antithrombotic therapy (See "Transcatheter aortic valve implantation: Antithrombotic therapy".)

-Endocarditis prophylaxis – All patients with prosthetic valves, including those who have undergone TAVI, are considered among those at highest risk for endocarditis, and therefore should receive optimal dental hygiene and care as well as antibiotic prophylaxis for bacterial endocarditis for relevant high-risk procedures. (See 'Endocarditis prophylaxis' above and "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

•Management of comorbid conditions – Patients undergoing TAVI commonly have one or more comorbid conditions that require ongoing follow-up and treatment, including hypertension (observed in approximately 90 percent of patients), CAD, heart failure (HF), chronic kidney disease, and diabetes mellitus. These conditions are generally managed according to standard evidence-based recommendations. (See 'Management of comorbid conditions' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff thank Stephen Brecker, MD, who contributed to earlier versions of this topic review.