Transcatheter aortic valve implantation (TAVI):Indications and Contraindications

This new approach for the treatment of symptomatic patients with severe aortic stenosis (AS) has been shown to be feasible and safe in patients at very high or prohibitive surgical risk. 

The following are indications for Aortic Valve Replacement (AVR) for severe Aortic Stenosis that apply to either surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI):

• AVR is recommended for patients with severe high-gradient AS who have symptoms by history or on exercise testing (stage D1).

• AVR is suggested in symptomatic patients with low-flow/low-gradient severe AS with reduced left ventricular ejection fraction (LVEF; stage D2) with a low-dose dobutamine stress study that shows an aortic velocity ≥4.0 m/s (or mean pressure gradient ≥40 mmHg) with a valve area ≤1.0 cm2 at any dobutamine dose.

• AVR is suggested in symptomatic patients who have low-flow/low-gradient severe AS (stage D3) who are normotensive and have an LVEF ≥50 percent if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms.

The following are indications for AVR for severe AS that apply only to SAVR:

• AVR is recommended for asymptomatic patients with severe AS (stage C2) and LVEF < 50 percent.

• AVR is suggested (weak recommendation) in asymptomatic patients (stage C1) with severe AS and decreased exercise tolerance or an exercise fall in blood pressure.

  See below indications and contraindications for TAVI.
The recommendations produced by European and American guidelines are rather similar. Both sets of guidelines indicate that a decision should be made by the multidisciplinary Heart Team. TAVI should only be performed in hospitals with cardiac surgery on-site. 

Contraindications for TAVI.

Absolute contraindications include the absence of a Heart Team and no cardiac surgery on-site, appropriateness of TAVI not confirmed by the Heart Team, estimated life expectancy < 1 year, comorbidity suggesting lack of improvement of quality of life, inadequate annulus size ( < 18 mm, > 29 mm), active endocarditis, symmetric valve calcification, short distance between the annulus and the coronary ostium, and plaques with mobile thrombi in the ascending aorta.

Relative contraindications include inadequate vascular access for transfemoral or subclavian approach (such patients could be treated from the transapical approach), bicuspid valve (no longer applicable), haemodynamic instability, and severe LV dysfunction.

Source: escardio.org