**4. Patient selection for TAVR**

Patient evaluation is directed towards identifying patients where significant improvement in the quality and duration of life is expected with AVR and avoid unnecessary intervention where the benefit is unlikely due to other confounding co-morbidities.

Extreme comorbidities that overwhelm the benefit of TAVR may render the procedure futile as shown in PARTNER cohort B.

The essential components for patient selection include:

	- a.Accurate valve sizing
	- b.Vascular access planning

## **4.1 Clinical risk stratification**

Important components of clinical risk stratification are mentioned in **Table 3**. STS-PROM and Euroscore II are the two most commonly used integrated risk scoring calculators used to assess surgical risk.

STS risk scoring system had been extensively utilized in clinical decision making for TAVR. SAVR, components of which are showed in **Table 4**.

STS score <4% is low risk.

≥4%, <8% is intermediate risk.

>8% is high risk.


**55**

survival.

ate TAVR patients.

and catheterisation laboratory team.

cognitive impairment and mood disorders.

**4.3 The anticipated benefit of TAVR**

have the greatest symptomatic benefit.

**4.2 Geriatric risk stratification**

management.

**Table 4.**

*Transcatheter Aortic Valve Replacement: Clinical Indications and Outcomes*

Concept of heart team: doctors from various specialties as a team need to evalu-

Multidisciplinary team approach provides an opportunity for active participation of doctors from multiple specialties and share views on different aspects of patient health care and also to counsel patient relatives on an anticipated line of

Beyond the traditional co-morbidities like DM and HTN, the elderly population also need particular attention in terms of advanced frailty, disability in activities of daily living, malnutrition, mobility impairment, low muscle mass and strength,

Trial evidence consistently shows, treatment with TAVR in patients with symptomatic severe AS results in reduction of all-cause mortality, improved duration of

Patients symptomatic because of severe AS not because of other comorbidities

Patient pre-operative symptom status can be assessed by Kansas city cardiomy-

The team should consist of referring physician, Clinical Cardiologist, Interventional cardiologist, cardiothoracic surgeon, Cardiac anaesthesiologist, dedicated cardiac imaging specialist, Valve clinic coordinator, dedicated nursing

*Variables included in STS PROM and variables not included in STS PROM.*

The commonly used assessment tools are shown in **Table 5**.

opathy questionnaire (KCCQ ) [13] and can be followed up linearly.

*DOI: http://dx.doi.org/10.5772/intechopen.84909*

**Table 3.** *Clinical predictors of increased risk.* *Transcatheter Aortic Valve Replacement: Clinical Indications and Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84909*


#### **Table 4.**

*Aortic Stenosis - Current Perspectives*

**4. Patient selection for TAVR**

2.Geriatric risk stratification

3.Anticipated clinical benefit and

a.Accurate valve sizing

**4.1 Clinical risk stratification**

STS score <4% is low risk. ≥4%, <8% is intermediate risk.

>8% is high risk.

b.Vascular access planning

scoring calculators used to assess surgical risk.

for TAVR. SAVR, components of which are showed in **Table 4**.

procedure futile as shown in PARTNER cohort B.

4.Assessment of patient's goals and preferences

The essential components for patient selection include:

1.Clinical risk stratification with emphasis on heart team

co-morbidities.

Patient evaluation is directed towards identifying patients where significant improvement in the quality and duration of life is expected with AVR and avoid unnecessary intervention where the benefit is unlikely due to other confounding

Extreme comorbidities that overwhelm the benefit of TAVR may render the

5.Anatomic assessment: MDCT as standard. 3D TEE as an alternative.

Important components of clinical risk stratification are mentioned in **Table 3**. STS-PROM and Euroscore II are the two most commonly used integrated risk

STS risk scoring system had been extensively utilized in clinical decision making

**54**

**Table 3.**

*Clinical predictors of increased risk.*

*Variables included in STS PROM and variables not included in STS PROM.*

Concept of heart team: doctors from various specialties as a team need to evaluate TAVR patients.

Multidisciplinary team approach provides an opportunity for active participation of doctors from multiple specialties and share views on different aspects of patient health care and also to counsel patient relatives on an anticipated line of management.

The team should consist of referring physician, Clinical Cardiologist, Interventional cardiologist, cardiothoracic surgeon, Cardiac anaesthesiologist, dedicated cardiac imaging specialist, Valve clinic coordinator, dedicated nursing and catheterisation laboratory team.

#### **4.2 Geriatric risk stratification**

Beyond the traditional co-morbidities like DM and HTN, the elderly population also need particular attention in terms of advanced frailty, disability in activities of daily living, malnutrition, mobility impairment, low muscle mass and strength, cognitive impairment and mood disorders.

The commonly used assessment tools are shown in **Table 5**.

#### **4.3 The anticipated benefit of TAVR**

Trial evidence consistently shows, treatment with TAVR in patients with symptomatic severe AS results in reduction of all-cause mortality, improved duration of survival.

Patients symptomatic because of severe AS not because of other comorbidities have the greatest symptomatic benefit.

Patient pre-operative symptom status can be assessed by Kansas city cardiomyopathy questionnaire (KCCQ ) [13] and can be followed up linearly.

### **4.4 Patients goals and preferences**

The assessment of futility must include consideration of patient's values, goals, and preferences.

Shared decision-making requires both patient and provider share information, work toward a consensus and reach agreement on the course of action.

In the TAVR population, when benefit in symptom relief aligns with a patient's goals, care may not futile.

However, when life prolongation and symptom relief is not anticipated, care may be futile.

TAVR is not recommended in patients with a life expectancy of <1 year, or if the benefit of TAVR will be less obvious in the backdrop of multiple co-morbidities.

#### **4.5 Anatomic assessment**

Assessment of valve calcification, valve anatomy, annulus size, coronary height, an angle of implantation, size of sinuses of Valsalva, ascending aorta and peripheral vascular access by multidetector computerized tomography scan (MDCT) is an integral part of pre TVAR work up.

#### *4.5.1 Aortic annulus*

Annulus is a virtual ring formed by basal hinge points of the valve cusps. The measurement of annulus size is a very important step as it determines the size of the TAVR valve.

Prosthesis undersizing causes the risk of significant Paravalvular leak (PVL) or valve embolization, if oversized, disruption of the aortic root and cause annular rupture or impingement on conduction system and may cause bundle branch block or complete heart block.

**57**

*Transcatheter Aortic Valve Replacement: Clinical Indications and Outcomes*

3D TEE and MDCT are the two most commonly used imaging methods for

MDCT is a non-invasive procedure, the ability to measure annulus during any part of the cardiac cycle and provide additional information like valve calcification, distribution of valve calcification, sizes of sinus of valsalva (SOV), coronary ostia distance from the annulus, makes it imaging of choice unless contraindicated in

MDCT because of excellent resolution provides a virtual roadmap for vasculature and allows identification of vessel size, tortuosity, calcification, and luminal diameter, which allows the planning of access routes with a view to minimizing

TAVR has seen an overall decline in peri-procedural complications over time,

According to transcatheter valve therapy (TVT data), 30-day in-hospital mor-

This part of the chapter briefly reviews about important complications post TAVR.

Access site complications incidence depends upon the method of localization and the location of the puncture site, the need for multiple punctures and the size of the sheath used. The incidence of major vascular complications showed a decreasing trend attributed to technical innovations reducing sheath size and valve delivery systems.

Complications associated with TAVR are as listed in **Table 6**.

tality has decreased from 7.5% in 2012 to 4.6% in 2015 [15].

*DOI: http://dx.doi.org/10.5772/intechopen.84909*

annulus measurement.

*Complications of TAVR.*

**Table 6.**

view of kidney injury [14].

*4.5.2 Vascular access planning*

vascular complication rate.

**5. Complications of TAVR**

partly owing to newer technology and expertise.

**5.1 Major vascular access site complications**

*Transcatheter Aortic Valve Replacement: Clinical Indications and Outcomes DOI: http://dx.doi.org/10.5772/intechopen.84909*

**Table 6.** *Complications of TAVR.*

*Aortic Stenosis - Current Perspectives*

**4.4 Patients goals and preferences**

and preferences.

*Geriatric assessment tools.*

**Table 5.**

may be futile.

goals, care may not futile.

**4.5 Anatomic assessment**

*4.5.1 Aortic annulus*

or complete heart block.

TAVR valve.

integral part of pre TVAR work up.

The assessment of futility must include consideration of patient's values, goals,

Shared decision-making requires both patient and provider share information,

In the TAVR population, when benefit in symptom relief aligns with a patient's

TAVR is not recommended in patients with a life expectancy of <1 year, or if the benefit of TAVR will be less obvious in the backdrop of multiple co-morbidities.

Assessment of valve calcification, valve anatomy, annulus size, coronary height, an angle of implantation, size of sinuses of Valsalva, ascending aorta and peripheral vascular access by multidetector computerized tomography scan (MDCT) is an

Annulus is a virtual ring formed by basal hinge points of the valve cusps. The measurement of annulus size is a very important step as it determines the size of the

Prosthesis undersizing causes the risk of significant Paravalvular leak (PVL) or valve embolization, if oversized, disruption of the aortic root and cause annular rupture or impingement on conduction system and may cause bundle branch block

However, when life prolongation and symptom relief is not anticipated, care

work toward a consensus and reach agreement on the course of action.

**56**

3D TEE and MDCT are the two most commonly used imaging methods for annulus measurement.

MDCT is a non-invasive procedure, the ability to measure annulus during any part of the cardiac cycle and provide additional information like valve calcification, distribution of valve calcification, sizes of sinus of valsalva (SOV), coronary ostia distance from the annulus, makes it imaging of choice unless contraindicated in view of kidney injury [14].

#### *4.5.2 Vascular access planning*

MDCT because of excellent resolution provides a virtual roadmap for vasculature and allows identification of vessel size, tortuosity, calcification, and luminal diameter, which allows the planning of access routes with a view to minimizing vascular complication rate.
