Valvular Heart Disease

How Well Do You Know the Indications for Transfemoral Aortic Valve Implantation?

AUTHORS:
Hannah Goymer • Ahmed Zaky, MD, MS, MPH

AFFILIATIONS:
Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham

CITATION:
Goymer H, Zaky A. How well do you know the indications for transfemoral aortic valve implantation? [published online April 8, 2020]. Cardiology Consultant.

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Ahmed Zaky, MD, MS, MPH, Professor and Associate Vice Chair for Cardiac Anesthesia Quality and Safety, Division of Cardiothoracic and Critical Care Anesthesiology, University of Alabama at Birmingham, 950 Jefferson Tower, 625 19th St S, Birmingham, AL 35249-6810 (azaky@uabmc.edu)

How well do you know the indications for TF-TAVI? Take this quiz to test your knowledge.



Transfemoral transcatheter aortic valve implantation (TF-TAVI) has become the standard of care for patients with prohibitive risk for surgical aortic valve replacement (SAVR).1,2 Recently, the indications for TF-TAVI have been extended to include patients with intermediate and low risk, where TF-TAVI was shown to be noninferior to SAVR in the short term.3,4 Multiple predictive risk models help determine not only the safety of the procedure, but also the benefits conferred by TF-TAVI.

However, despite that the choice of procedure between TF-TAVI and SAVR depends heavily on patient “risk,” the currently available risk scores have strong limitations. For example, the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) are scoring systems that are used to predict the risk of SAVR and not of TF-TAVI. Therefore, their applicability is limited in TF-TAVI.5 Furthermore, the risk scores that are specifically used for transcatheter aortic valve replacement (TAVR) and that were developed by the STS and the American College of Cardiology Transcatheter Valve Therapy (TVT) Registry have limited applicability and validation and have focused only on in-hospital or postprocedural 30-day mortality.6 Therefore, there is a need for an interdisciplinary advisory pathway to help clinicians in daily decision-making on what to choose for their patients.

The current consensus is an interdisciplinary statement jointly initiated by a German group of interventional cardiologists at the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte) and cardiac surgeons to provide an up-to-date, comprehensive, evidence-based decision matrix for daily practice.7 The matrix of indications includes age, currently used risk scores, contraindications for SAVR (eg, porcelain aorta), cardiovascular criteria pro TF-TAVI, additional criteria pro TF-TAVI (eg, frailty, comorbidities, organ dysfunction), contraindications against TF-TAVI (eg, endocarditis), and cardiovascular criteria pro SAVR (eg, bicuspid valve anatomy). This interdisciplinary consensus may aid clinicians as they make individual decisions on patients undergoing TF-TAVI.

REFERENCES:

  1. Makkar RR, Fontana GP, Jilaihawi H, et al; PARTNER Trial Investigators. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med. 2012;366(18):1696-1704. doi:10.1056/NEJMoa1202277
  2. Kapadia SR, Leon MB, Makkar RR, et al; PARTNER Trial Investigators. 5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet. 2015;385(9986):2485-2491. doi:10.1016/S0140-6736(15)60290-2
  3. Fu J, Popal MS, Li Y, et al. Transcatheter versus surgical aortic valve replacement in low and intermediate risk patients with severe aortic stenosis: systematic review and meta-analysis of randomized controlled trials and propensity score matching observational studies. J Thorac Dis. 2019;11(5):1945-1962. doi:10.21037/jtd.2019.04.97
  4. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374(17):1609-1620. doi:10.1056/NEJMoa1514616
  5. O’Brien SM, Shahian DM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2—isolated valve surgery. Ann Thorac Surg. 2009;88(1 suppl):S23-S42. doi:10.1016/j.athoracsur.2009.05.056
  6. Martin GP, Sperrin M, Ludman PF, et al. Inadequacy of existing clinical prediction models for predicting mortality after transcatheter aortic valve implantation. Am Heart J. 2017;184:97-105. doi:10.1016/j.ahj.2016.10.020
  7. von Scheidt W, Welz A, Pauschinger M, et al. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI): Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments. Clin Res Cardiol. 2020;109(1):1-12. doi:10.1007/s00392-019-01528-5