TAVI (Transcatheter Aortic Valve Implantation)
Definition
Transcatheter aortic valve implantation (TAVI) is a catheter-based technique for delivering and deploying a bioprosthetic aortic valve without open-heart surgery. Most commonly performed via transfemoral access. TAVI has progressively expanded from inoperable/high-risk patients to intermediate- and low-risk populations.
Key Concepts
Evidence Base — TAVI vs SAVR
- High-risk patients: TAVI non-inferior or superior to SAVR (PARTNER 1, CoreValve High Risk)
- Intermediate-risk: TAVI non-inferior (PARTNER 2, SURTAVI)
- Low-risk patients: TAVI non-inferior to SAVR at 5 years (PARTNER 3, Evolut Low Risk, DEDICATE)
- No significant difference in stroke or mortality at mid-term; TAVI has lower AKI, AF, major bleeding; SAVR has lower paravalvular leak and pacemaker rates sources/vhd-esc-2025
very high
Expanded Indications (2025)
- Symptomatic severe AS: All risk levels with appropriate anatomy (Heart Team decision)
- Asymptomatic severe AS with early intervention (new Class IIa): Alternative to watchful waiting in patients with LVEF ≥50%, normal exercise test, low procedural risk (EARLY TAVR trial)
- BAV stenosis at high surgical risk (new Class IIb B): If anatomy suitable per Heart Team — historically excluded from major RCTs
- Severe AR in inoperable patients (new Class IIb B): If anatomy suitable — off-label use of non-dedicated devices carries ~10% risk of second valve implantation or surgical conversion; dedicated TAVI devices associated with high pacemaker rate (~24%)
- Moderate AS + HFrEF: insufficient evidence for routine TAVI at this time sources/vhd-esc-2025
very high
TAVI vs SAVR — Selection Factors
Heart Team decision integrating:
- Age and life expectancy: SAVR preferred in younger patients (<65 years aortic; <70 years mitral) with longer life expectancy; TAVI acceptable in older patients with limited life expectancy
- Anatomical factors: Narrow aortic root, low coronary ostia, commissural misalignment, severe LVOT calcification, BAV morphology → favour SAVR or require careful TAVI planning
- Procedural risk: EuroSCORE II or STS-PROM; high surgical risk favours TAVI
- Patient preference and values: Informed patient preference is Class I consideration sources/vhd-esc-2025
very high
CAD Management Before TAVI
- CCTA sufficient to rule out significant CAD if procedural planning CT is of sufficient quality (new Class IIa)
- PCI Class IIa B: ≥90% stenosis in vessels ≥2.5 mm before TAVI (NOTION-3 trial)
- PCI Class IIb B: ≥70% stenosis in proximal segments of main vessels before any transcatheter valve intervention
- Consider coronary access post-TAVI: valve frame height, commissural alignment, narrow aortic root may limit future coronary access sources/vhd-esc-2025
very high
Procedural Planning
- CCT mandatory: annulus dimensions, aortic root anatomy, coronary ostia height, LVOT calcification, optimal fluoroscopic projections, iliofemoral access assessment
- TOE or CMR as alternatives when CCT is difficult (renal failure, arrhythmia)
- Commissural alignment optimisation important for future coronary access
Antithrombotic Therapy After TAVI — ESC 2025
- No OAC indication:
- ASA 75–100 mg/day for 12 months: Class I A (POPular TAVI cohort A)
- Long-term ASA after 12 months: Class IIa C
- DAPT: not recommended (Class III B) — no additional benefit, excess bleeding
- Routine OAC: not recommended (Class III A) — GALILEO trial halted for harm (rivaroxaban + ASA)
- With OAC indication (AF, etc.): OAC alone Class I B; OAC + clopidogrel not recommended (excess bleeding, POPular TAVI cohort B)
- DOAC vs VKA after TAVI with OAC indication: no definitive superiority of either (ATLANTIS, ENVISAGE-TAVI AF) sources/vhd-esc-2025
very high
Antithrombotic Therapy After TAVI — ACC/AHA 2020
- No OAC indication: ASA 75–100 mg daily Class IIa B-R; DAPT (ASA + clopidogrel 75 mg) for 3–6 months Class IIb B-NR; VKA INR 2.5 for ≥3 months Class IIb B-NR
- Low-dose rivaroxaban 10 mg + ASA: Class III:Harm B-R — contraindicated without other OAC indication (GALILEO harm)
- Note: ESC 2025 upgraded ASA to Class I A and made DAPT Class III; ACC/AHA 2020 had less definitive evidence and rated ASA as Class IIa sources/VHD-AHA-2020
very high
Post-Procedural Follow-up
- TTE within 3 months, at 1 year, and annually thereafter
- Monitor for: structural valve deterioration (SVD), hypo-attenuated leaflet thickening (HALT), paravalvular leak, new conduction abnormalities
- Right heart catheterisation not routinely needed; CCT/PET if prosthetic valve thrombosis or endocarditis suspected
NCS Timing After TAVI
- NCS early after TAVI (COR 2a): Noncardiac surgery may proceed even within the first 30 days after a successful TAVI in patients with time-sensitive surgical conditions — in contrast to DES where NCS ≤30 days carries high thrombotic risk. (sources/periop-aha-2024, rating: very high)
- Rationale: Successful TAVI relieves the fixed LVOT obstruction; the predominant perioperative risk shifts back to the non-valvular comorbidities and general surgical risk rather than valve-related haemodynamics. (sources/periop-aha-2024, rating: very high)
- Continue aspirin perioperatively: COR 2a — aspirin should be maintained for antiplatelet coverage following TAVI during perioperative period; withholding risks early valve leaflet thrombosis. (sources/periop-aha-2024, rating: very high)
- NCS after MV TEER (transcatheter edge-to-edge repair, e.g., MitraClip): Proceeding with NCS after successful MV TEER is also reasonable (COR 2a); same principle as post-TAVI — resolution of the primary valvular pathology removes the key haemodynamic obstacle. (sources/periop-aha-2024, rating: very high)
Contradictions / Open Questions
- Long-term durability beyond 8–10 years is the critical unknown — valve-in-valve procedures for TAVI failure are technically feasible but associated with higher residual gradients
- TAVI for AR: limited evidence; dedicated devices promising but high pacemaker rate; no RCT vs SAVR
- TAVI for BAV: excluded from most major RCTs; observational data suggest higher rates of paravalvular leak, second valve implantation, and pacemaker requirement
- Optimal antithrombotic strategy in the first 12 months after TAVI with concomitant OAC: VKA vs DOAC — still debated
Connections
- Related to concepts/Aortic-Stenosis
- Related to concepts/Aortic-Regurgitation
- Related to concepts/Valvular-Heart-Disease
- Related to concepts/Structural-Valve-Deterioration
- Related to entities/Atrial-Fibrillation
- Related to concepts/Perioperative-Cardiovascular-Assessment
- Related to sources/periop-aha-2024