Cardiothoracic Surgery: Aortic Valve Replacement (AVR)

Aortic Valve Replacement (AVR)

Approach

  • Surgical Aortic Valve Replacement (SAVR)
  • Transcatheter Aortic Valve Implantation (TAVI)
    • Also Known as: Transcatheter Aortic Valve Replacement (TAVR)

Choice in Approach

  • TAVI Generally Preferred
    • Lower Mortality
    • Lower Rates of Acute Kidney Injury, New-Onset Atrial Fibrillation or Major Bleeding
  • Indications for Surgical AVR:
    • Presence of Other Pathology Requiring Cardiac Surgery
    • High Surgical Risk if Transfemoral TAVI Not Feasible
    • Intermediate Surgical Risk with High-Risk Anatomic Features (Adverse Aortic Root, Low Coronary Ostia Height, Heavily Calcified Bicuspid Valve)
    • Low Surgical Risk if Any of the Following:
      • Age < 65
      • Transfemoral TAVI Not Feasible
      • Bicuspid Aortic Valve
      • High-Risk Anatomic Features (Adverse Aortic Root, Low Coronary Ostia Height, Heavily Calcified Bicuspid Valve)

Transcatheter Aortic Valve Implantation (TAVI) Contraindications

  • Estimated Life Expectancy < 12 Months Due to Noncardiac Comorbidities
  • Improvement in Quality of Life Unlikely Due to Comorbidities
  • Severe Other Valve Disease with Major Contribution to Symptoms if Treatable Only by Surgery
  • Inadequate Annulus Size
  • Active Endocarditis
  • Anatomic Features Associated with High Risk of Coronary Ostium Obstruction (Asymmetric Calcification, Low Ostia Height or Adverse Aortic Root)

Prosthetic Valves

  • Mechanical Valves
    • More Durable – Lifelong
    • Requires Lifelong Anticoagulation
    • Improved Survival in Younger Patients
  • Bioprosthetic Valves (Pericardial or Xenograft (Porcine, Bovine or Equine))
    • Less Durable & Higher Rates of Reoperation Due to Structural Degeneration
      • Higher Risk in Younger Patients (Due to Longer Lifespan & Increased Activity)
      • Risk Structural Deterioration at 15-Years:
        • 20-Year-Olds: 50%
        • 40-Year-Olds: 30%
        • 70-Year-Olds: < 10%
    • Does Not Require Lifelong Anticoagulation
    • Improved Survival in Older Patients (Aortic > 55 Years; Mitral > 70 Years)
    • Indications:
      • Elderly or Life-Expectancy Shorter than that of the Graft
      • Possible Future Pregnancy
      • Contraindication to Anticoagulation