Chapter 15: Aortic Valve Management

Class I

AVR is indicated with severe AS who meet the criteria for valve replacement. (LOE: C)

Class IIa

AVR is reasonable with moderate AS (MG 30–50 mmHg or Doppler velocity 3–4 m/s). (LOE: B)

Class IIb

AVR may be considered with mild AS (MG < 30 mmHg or Doppler velocity < 3 m/s) when there is evidence, such as moderate-to-severe valve calcification, that progression may be rapid. (LOE: C)

Abbreviations: AS, aortic stenosis; AVR, aortic valve replacement; CABG, coronary artery bypass graft; LOE, level of evidence; MG, mean gradient. Adapted from Bonow et al.¹¹⁰

2D ME 5C

0-10°

1. Retrograde wires crossing into LV, with a clear view of LV apex
2. Ensures no wires entangled in MV apparatus

2D ME LAX 

120-140°

2D ME LAX

120-140°

1. Prosthesis positioning during balloon dilation and live depiction of AoV calcification behavior during implantation (especially when less visible fluoroscopically)
2. Monitor AoV leaflet behavior as pushed into sinuses

3D ME LAX 

30-45°

2D multiplane imaging (ME LAX and SAX)

2D ME 5C

0-10°

1. CFI post-procedure for success and complications
2. Differentiate transvalvular and paravalvular leaks

2D ME SAX

120-140°

Live 3D-MPR

30-45°

Abbreviations: 2D, two-dimensional; 3D, three dimensional; 5C, five-chamber; AoV, aortic valve; CFI, color flow imaging; LAX, long-axis; LV, left ventricular; ME, mid-esophageal; MPR, multiplane reconstruction; MV, mitral valve; SAX, short-axis; TEE, transesophageal echocardiography; THV, transcatheter heart valve. Adapted from Raja-Shariff et al.  1

Major (One of the following)

1. Cardiac structure* perforation, injury, or compromise resulting in death, VARC type ≥2 bleeding, hemodynamic compromise or tamponade, or requiring unplanned surgical or percutaneous intervention
2. New pericardial effusion resulting in death, VARC type ≥2 bleeding, hemodynamic compromise or tamponade, or requiring unplanned surgical or percutaneous intervention
3. Coronary obstruction† resulting in death, hemodynamic compromise, myocardial infarction, or unplanned surgical or percutaneous intervention. Coronary obstruction may be acute (during the procedure) or delayed (after completion of the procedure)
4. Coronary artery access difficulties for needed coronary angiography or intervention, resulting in death, hemodynamic compromise, myocardial infarction, coronary or aortic root injury, compromise in aortic valve prosthesis integrity, unplanned surgical or percutaneous intervention, or the inability to perform the intended procedure

Minor (One of the following)

1. Cardiac structure* perforation, injury, or compromise not resulting in death, VARC type ≥ 2 bleeding, hemodynamic compromise or tamponade, or requiring unplanned surgical or percutaneous intervention
2. New pericardial effusion not resulting in death, VARC type ≥2 bleeding, hemodynamic compromise or tamponade, or requiring unplanned surgical or percutaneous intervention
3. Coronary obstruction not resulting in death, hemodynamic compromise, myocardial infarction, or unplanned surgical or percutaneous intervention.
4. Coronary artery access difficulties for needed coronary angiography or intervention, not resulting in death, hemodynamic compromise, myocardial infarction, coronary or aortic root injury, compromise in aortic valve prosthesis integrity, unplanned surgical or percutaneous intervention, or the inability to perform the intended procedure

*Aortic annulus, left ventricular outflow tract, ventricular septum, left or right ventricle, atrial septum, left or right atrium, mitral valve apparatus, tricuspid valve apparatus, coronary artery, and coronary sinus. Also includes any new inter-cardiac cavity communication (e.g. VSD), and new left-to-right or right-to-left shunt.
†Angiographic or echocardiographic evidence of a new partial or complete obstruction of a coronary ostium or an epicardial coronary artery, either by the valve prosthesis itself, the native leaflets, embolized material (e.g. calcification, thrombus, and/or tissue), external device compression, or the consequence of coronary artery instrumentation (e.g. dissection, occlusion, embolization), occurring during or after the procedure, and with objective evidence of ischemia (i.e. new ST-segment deviation on electrocardiogram) or symptoms. Excludes coronary complications from concomitant or subsequent planned percutaneous intervention for significant coronary artery disease.

Abbreviations: VARC, Valve Academic Research Consortium

Adapted from Varc-3¹⁰⁷

1. Conversion to open surgery

Conversion to open sternotomy or thoracotomy using CPB secondary to any procedure-related complication or failed intended transcatheter approach. Should be classified as:

1. Intra-procedural conversion: during the index procedure
2. Periprocedural conversion: #30 days after the index procedure
3. Delayed conversion: >30 days after the index procedure

2. Unplanned use of mechanical circulatory support†

3. Implantation of multiple (>1) transcatheter valves during the index hospitalization

4. Valve malposition: should be classified as:
1. Valve migration: After initial correct positioning, the valve prosthesis moves upward or downward, within the aortic annulus from its initial position, without valve embolization
2. Valve embolization: The valve prosthesis moves either upward or downward after final deployment such that it loses contact with the aortic annulus
3. Ectopic valve deployment: Irretrievable deployment of a valve prosthesis at a site other than the intended position because of valve embolization or inability to deliver the prosthesis to the desired location

5. Paravalvular regurgitation (see Table 15.8)

*Individual events should be collected so that specific event rates can be determined.
†Mechanical circulatory support includes: CPB, ECMO, transcatheter pumps (e.g. Impella) or IABP. Abbreviations: CPB, cardiopulmonary bypass; ECMO, extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump. Adapted from Varc-3 ¹⁰⁷