What is required in the Pre-Operative assessment?

A standard TAVI workup includes

• Clinical assessment – To determine the indication for TAVI and its urgency.
• Surgical and Frailty risk scoring – This is done using various scoring systems like ACS NSQIP etc.
• Blood investigations – Like a Full Blood Count, blood biochemistry panel, liver function tests, coagulation studies, arterial blood gases, random blood sugars, etc.
• Echocardiography – This is important to assess the status of the aortic valve, which influences the surgery. Also, the ejection fraction is measured, which is a strong indicator of surgical mortality.
• Pulmonary function tests, including chest x-ray – Any lung abnormalities must be found beforehand and dealt with, as it can affect the outcome of the surgery.

Special pre-op workup requirements for TAVI are as follows;

• Access route evaluation
  1. Usually, the transfemoral route is the typical access point through which the catheter is introduced.
     Iliofemoral angiography is essential to assess the size, tortuosity, and degree of calcification, as these affect catheterization success. CT can also be used to evaluate but is not as effective.
  2. Other access routes, like subclavian and carotid vessels, also need to be imaged using angiography if possible.
• Hemodynamic assessment – This is essential to grade the degree of aortic stenosis. Echocardiography is the usual non-invasive procedure to measure this, but cardiac catheterization can also provide valuable information regarding chamber pressures and flow rates.
• Diagnostic coronary angiography – This is required to identify and treat any existing coronary artery disease, as they severely affect the success of the surgery. This can be done via the femoral route due to the concurrent need to assess the femoral vessels. An angiography also provides valuable information regarding coronary Ostia, which affects valve placement.
• Aortogram clarifies whether the aorta is suitable enough to allow the catheter to pass up to the heart. It also shows the presence, if any, of aortic valve calcifications and co-existing aortic regurgitation, all of which need to be considered before surgery. A transesophageal echo can assist with this as well.
• Right heart catheterization – This is carried out to assess the presence of pulmonary hypertension, which increases mortality following TAVI.

Conclusion

As evidenced by this article, while TAVI is a revolutionary method to treat severe AS with much less mortality, the procedure’s success depends heavily on an excellent pre-op workup. If you are from around Mumbai and feel like TAVI is the way for you, don’t hesitate to contact the offices of Dr. Ankur Phatarpekar, who is the best heart specialist/cardiologist in Mumbai. We will ensure that the proper assessment is done and excellent care is provided to ensure the best outcome for you.