Feb. 19, 2025
Innovative technology can help replace a patient's narrowed aortic valve that slows blood flow from the heart. Transcatheter aortic valve replacement (TAVR), also called transcatheter aortic valve implantation (TAVI), is a minimally invasive treatment for aortic valve stenosis. The procedure uses smaller incisions than open-heart surgery. TAVR may be used if a biologic tissue aortic valve isn't working well or if another health condition makes open-heart valve replacement surgery too risky.
At Mayo Clinic Cardiovascular Medicine, patients with aortic valve stenosis are evaluated by a multidisciplinary team of heart valve specialists in the Valvular Heart Disease Clinic. Cardiovascular experts with specialized TAVR training treat patients. Mayo Clinic specialists perform more than 600 TAVR procedures a year.
Kimberly A. Holst, M.D., a cardiothoracic surgeon and interventional cardiologist at Mayo Clinic in Rochester, Minnesota, explains how heart specialists determine when TAVR is beneficial for patients.
Minimally invasive TAVR
Transcatheter aortic valve replacement (TAVR) is a percutaneous approach for aortic valve replacement. Access is typically performed through the femoral arteries; wires and catheters are used to cross the aortic valve and then deploy a biologic prosthesis. Commercially available devices — balloon-expandable valves or self-expanding valves — are primarily used to treat aortic stenosis through use of radial force within the native aortic annulus.
Aortic valve replacement
The preferred aortic valve replacement (AVR) approach for each patient depends on their specific anatomy, comorbidities and presence of concomitant disease along with lifetime planning of aortic valve disease.
- Surgical risk. While TAVR previously was reserved for patients at high risk to undergo cardiac surgery, current indications include patients above age 65 from high through low risk of surgery.
- Aortic valve anatomy. In addition to surgical risk, the anatomy of the aortic valve and presence of concomitant disease such as aortic aneurysm, coronary artery disease, atrial fibrillation or other valvular heart disease should be considered to ensure that each patient is treated with a comprehensive approach.
- Patient longevity. Biologic prostheses have limited durability, while mechanical prostheses require lifelong anticoagulation. Younger age generally favors mechanical prosthesis. Older age, frailty and a less likely need for redo aortic valve replacement favor biologic prosthesis, including TAVR.
Anatomic considerations of TAVR
Aortic annular size along with the degree and distribution of calcification are critical considerations in TAVR. There must be sufficient calcium and sizing to allow for the transcatheter prosthesis to anchor. However, excessive, bulky calcium may increase the risk of aortic root injury with TAVR.
Most patients have tricuspid aortic valves. Bicuspid valves have variable anatomy and may be associated with asymmetric calcium distribution. The aortic root complex, consisting of the sinuses of Valsalva, coronary artery location and height of the sinotubular junction, is important for both initial deployment and impact feasibility of future valve-in-valve therapies.
Vascular access is also crucial. Transfemoral access is the preferred approach. However, in the event of significant peripheral vascular disease, alternative access sites may include carotid, subclavian and transcaval.
When to opt for a surgical aortic valve
Surgical valve replacement is an option in patients with concomitant disease requiring treatment and those who would benefit from a mechanical prosthesis who are fit to undergo cardiac surgery.
Many patients with multivalvular heart disease benefit from a comprehensive surgical approach. Consider surgery in patients with ascending aortic aneurysms, particularly in the setting of aortopathy associated with bicuspid aortic valves, contingent on size of the ascending aorta and rate of growth. Serious or complex coronary disease or both may be more feasible and appropriate to address with bypass grafts than with a percutaneous approach.
Surgery is preferred in patients with bulky and asymmetric calcium who are at increased risk of aortic annular injury with TAVR and those who would benefit from either aortic root replacement or aortic root enlargement. Size of native anatomy, either too small or large, may be more suitable for surgical AVR. Patients with a small aortic annulus, particularly younger patients with life expectancy exceeding valve durability, should be considered for surgical root enlargement, to facilitate placement of a larger prosthesis and subsequent TAV-in-SAV or mechanical prosthesis.
A patient-centered, team approach to concomitant cardiac disease during treatment of the aortic valve is essential.
Cutting-edge technological advancements
Mayo Clinic continues to advance the field of structural heart disease for aortic valve pathology on multiple fronts including valve-in-valve therapy with leaflet modification as needed, TAVR for aortic regurgitation, alternative access approach, and clinical trials focused on new devices and new applications for technology.
For more information
Refer a patient to Mayo Clinic.