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- J Vis Surgery
- v.4; 2018
J Vis Surg.2018; 4: 102.
Posted online May 14, 2018. do:10.21037/jovs.2018.04.02
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Transcatheter aortic valve replacement (TAVR) has emerged as a viable, minimally invasive, and widely adopted approach for the treatment of severe symptomatic aortic stenosis in patients at intermediate or high risk for surgical aortic valve replacement. Numerous studies have shown favorable results with TAVR in this population, particularly with TAVR transfemoral access. Transfemoral TAVI has been shown to be safer and is associated with less morbidity, shorter hospital stay, and faster recovery compared to traditional TAVI with an alternative thoracic access (transapical or transaortic). Despite iterative advances in transcatheter heart valve technology and delivery system, there remains a proportion of patients with iliofemoral arterial vessels that are too small for safe transfemoral TAVI. Paradoxically, these patients are generally at higher risk and therefore less favorable candidates for open surgery or traditional alternative access TAVI. With these considerations in mind, transcaval TAVR was developed as a fully percutaneous, non-surgical approach to aortic valve replacement in patients who are not candidates for traditional alternative access TAVR. In this manuscript, we describe the principles on which transcaval TAVR was developed, the results of the largest comprehensive study evaluating this technique, and we describe the technique used to perform this procedure in a case-based format.
Keywords:Transcatheter aortic valve replacement (TAVR), alternative access, transcava
Introduction (Figure 1)
Introduction to the cardiac procedure and equipment (1). Available:http://www.asvide.com/article/view/24742
Transcatheter aortic valve replacement (TAVR) was developed as a minimally invasive approach to aortic valve replacement in intermediate- or high-risk patients with severe symptomatic aortic stenosis as an alternative to surgical aortic valve replacement. TAVR is an established procedure; More than 250,000 procedures have been performed in more than 65 countries worldwide to date and more than 100,000 procedures have been performed in the US in the last 5 years (2).
Most cases of TAVR (>80%) can be performed using a percutaneous transfemoral approach (3). However, transfemoral access is not an option in all patients because the femoral and pelvic arteries are diseased or small, making it unsafe to pass the TAVR delivery sheath without high risk of injury. This has led to the development of alternative access approaches for transcatheter delivery of heart valves. Despite the development of several alternative access approaches for TAVR, most of these approaches are more invasive than transfemoral TAVR and many of them require a transthoracic (transapical/transaortic) access that is inferior compared to femoral access (4). This increases the risk to patients compared to transfemoral TAVR, which does not require surgery or instrumentation of the chest cavity. Given the generally high-risk nature of patients treated with a non-femoral approach, there has been great interest in developing an alternative percutaneous non-surgical approach to TAVI. Transcaval TAVR was developed with these considerations and objectives in mind.
Selection and evaluation of patients
The TAVR transcaval access was developed for patients who are not candidates for traditional transfemoral TAVR due to small pelvic arteries and for whom alternative traditional surgical access has been considered high risk. Transcaval access TAVR is a fully percutaneous transfemoral technique that accesses the abdominal aorta through the adjacent inferior vena cava (IVC), allowing transcatheter heart valve placement from a retrograde approach. This takes advantage of the large, distensible veins in the abdomen and pelvis to bring the valve into the aorta, thus bypassing the small, diseased arteries of the pelvis. Upon completion of the TAVR procedure, the arterial component of the venous-arterial bypass is closed with a nitinol cardiac occluder (Figure 2).
Illustrative transcaval access technique for TAVR. (A) Transcaval access is obtained via an electrified guidewire directed from the inferior vena cava to a loop in the abdominal aorta; (B) After delivery of a microcatheter to be exchanged for a rigid guidewire; (C) The transcatheter heart valve introducer sheath is advanced from the femoral vein into the abdominal aorta for conventional transfemoral retrograde transfemoral aortic valve replacement (TAVR); (D) The aortocaval access site is closed with a nitinol cardiac occluder.
Each TAVR candidate patient is evaluated with a specialized contrast-enhanced CT scan. When a patient is not a candidate for transfemoral TAVR, the preprocedure CT is reviewed for alternative access. In the transcaval TAVR setting, CT is evaluated for a calcium-free window in the right wall of the abdominal aorta, close to the vena cava, free of intervening structures where it is possible to cross from the inferior vena cava into the aorta. , therefore bypassing the iliofemoral vessels (5). Additionally, CT is used to determine salvation with a covered stent if closure with the occluder device fails.
The physiology of the transcaval access provides insight into why the transcaval access approach is feasible. Studies have shown that the opening created in the vena cava during the procedure serves to decompress aortic bleeding during transcaval access and closure (5). The pressure of the surrounding retroperitoneal (abdominal) space exceeds the venous pressure, causing blood to return from the aorta to the circulation via the vena cava. The vena cava is the lowest pressure in the abdomen and acts as a natural sink or reservoir for blood to flow from the aorta into the inferior vena cava (Figure 3).
Hemodynamic stability mechanism after transcaval access. The higher pressure in the relatively confined retroperitoneal space exceeds the venous pressure and causes aortic blood to return to the venous circulation through the nearby opening in the inferior vena cava (IVC). The result is an aortocaval fistula rather than hemodynamic collapse.
Initial animal studies conducted at the US National Institutes of Health demonstrated that animals tolerated aortocaval bypass even without closure and that transcaval access was feasible (6). The technique was then performed in humans and again the feasibility and safety of the technique was demonstrated in the first 19 patients who underwent aortocaval shunt closure with a nitinol occluder (7).
Subsequently, the transcaval approach was systematically evaluated in a multicenter prospective study of 100 patients (8). The study demonstrated that transcaval access was successful in 99% of high-risk patients enrolled in the study (tabla 1). Inpatient survival was 96% and 30-day survival was 92%, and there were no deaths as a direct result of transcaval access. Second Valve Academic Research Consortium (VARC-2) life-threatening bleeding was 7% and major vascular complications possibly related to transcaval access were 13% (mesa 2). In comparison, the rates of disabling or life-threatening bleeding for intermediate-risk patients in the PARTNER II study were 22.6% for transthoracic alternate access TAVI and 6.7% for transfemoral TAVI. Thus, life-threatening bleeding with transcaval TAVR in high-risk patients in this study compared favorably with bleeding rates in low-risk patients in the intermediate-risk PARTNER II study. In summary, this study confirmed that TAVR transcaval access was a safe and effective option for high-risk patients with limited options.
Baseline characteristics (N=100)
|year old||79,5 (73,0, 85,0)|
|Left ventricular ejection fraction, %||52,8±15,6|
|CHF (NYHA functional class)||3,2±0,6|
|Enlargement or dysfunction of the right ventricle||24|
|coronary artery disease||89|
|previous heart surgery||44|
|End-stage renal disease or dialysis||10|
|FGe, ml/min/1,73 m2||52,6±23,6|
|NT-pro-BNP/BNP, pg/mL||421 (183, 1.070)|
|Predicted risk of mortality from STS, %||9,6±6,3|
|Euroscore II predicted risk of mortality, %||10,9±9,8|
|TVT risk score, %||9,2±7,2|
|Reasons reported for site unsuitable for mainstream access|
|advanced lung disease||39|
|Factors that prevent transaortic access: porcelain aorta, compromised grafts, previous chest radiation, previous sternal wound infection, inadequate working length||53|
|Factors impeding transapical access: anterior transapical failure, chest radiation, chest wound infection, fatty myocardium||11|
|Inadequate diameter of the iliofemoral artery regardless of calcification or tortuosity||82|
Values are n (25º, 75ºpercentile), n, or mean ± SD. CHF, congestive heart failure; Egfr: estimated glomerular filtration rate; NYHA, New York Heart Association; NT-proBNP, N-terminal brain natriuretic peptide; STS, Society of Thoracic Surgeons; TVT, transcatheter valve therapy registry.
Results in 30 days (N=100)
|Death within 30 days||7 cardiovascular|
|1 No cardiovascular|
|myocardial infarction||2 periprocedimiento|
|Contrast-induced nephropathy requiring dialysis||2|
|Classification of acute kidney injury||Grade 0 (n=87)|
|Grade 1 (n=9)|
|Grade 2 (n=0)|
|Grade 3 (n=3)|
|Thrombocytopenia <50×103/µL||5 (4 with patent fistula)|
|Non-access-related bleeding (eg, gastrointestinal)||15|
|Transfusion during TAVR/after TAVR/during or after TAVR||30/14/35|
|Transfusion units among those transfused (median) (n=35/100)||2,0 (2,0, 4,0)|
|Follow-up CT scan before discharge||87|
|LOS post-TAVR (days), median (quarters)||4 [2-6]|
|Length of ICU stay post-TAVR (days), median (quartiles)||1 [1–3]|
|Initial safety of VARC-2 compound*||75|
*, Second Valve Academic Research Consortium Early Safety Compound (VARC-2) is 30 days free of mortality, stroke, life-threatening hemorrhage, stage 2 or 3 acute kidney injury, coronary obstruction requiring intervention, major vascular complication or valve-related dysfunction requiring a repeat procedure. CT, computed tomography; TAVI, percutaneous aortic valve replacement; LOS, residence time.
Equipment List (Tabla 3)
|Rings 6F or 7F 55 cm in various shapes (LIMA, RDC-1, Hockey Stick, FR/JR4)|
|Coronary guide wire 6 Fr JR4 90–100 cm|
|crossed guide wire|
|Astato XS 20 0,014”, 300 cm, Asahi|
|Confidence Pro 12 0.014”, 300cm, Asahi|
|Piggyback 145 cm, Vascular Solutions|
|Finecross MG 130 o 150 cm, Terumo|
|0.035” CXI straight tip microcatheter, Cook|
|1.25–2.00 mm NC coronary balloons may be needed to dilate the aortic side of the tract if microcatheters do not cross|
|Navicross 90 cm|
|CXI kitchen 90 cm|
|minnie 90 cm|
|Quick Cross Extreme 90 cm trenzado|
|Colector 90 cm|
|sheath guide wire|
|Lunderquist Extra Stiff 260 cm 0.035” Straight or simple curve|
|Edwards eSheath 14-16 F (depending on valve size)|
|Cook RCFW 18Fr×40 cm|
|XVFCW firing 20Fr×40 cm|
|Wing (aortic diameter + 5 mm, rounded)|
|Amplatz goose neck 15–35 mm|
|Needle driver, large|
|Tuohy-Borst + 3-way tap|
|Co-pilot + 3-way stopcock|
|Fence||deflectable guiding catheter|
|Agilis NxT SML Curl 71 cm 8,5 Fr|
|DiRex Boston Scientific 8.5 Fr/17 mm/71 cm|
|Amplatzer Torqueview 7 Fr 45o|
|Amplatzer ADO-1 12/10 Canal Occluder, Abbott|
|Amplatzer ADO-1 10/8 Canal Occluder, Abbott|
|Amplatzer ADO-1 8/6 Canal Occluder, Abbott|
|guide wire friendly|
|0.014” BMW 300 cm or other light or medium weight guide|
|Aortic Occlusion Balloon (1:1 size for aorta or oversized)|
|Cook Coda 32 mm (12 Fr)|
|Cook Coda 40 mm (14 Fr)|
|Reliant de Medtronic 46 mm (12 Fr)|
|Armada PTA 14 mm o Z-Med (7 Fr)|
|Cordis MaxiLD 16–18 mm (10 francs)|
|Bard Atlas/Atlas Gold 12-26 mm (7–12 Fr) diameter sized for 1:1 aorta|
|Occlusion balloon sheath|
|7-14 Fr × 10-14 cm, any hem (minimum Fr size, depending on the chosen balloon)|
|Covered stent/endograft (extension + Endologix delivery system): size chosen based on analysis of the aorta|
|Trivascular iliac branch extension Ovation iX 16 mm × 45 mm (DE 4.3 mm)|
|Trivascular iliac branch extension Ovation iX 18 mm × 45 mm (DE 4.3 mm)|
|Trivascular iliac branch extension Ovation iX 22 mm × 45 mm (DE 4.7 mm)|
|Trivascular iliac branch extension Ovation iX 28 mm × 45 mm (DE 5.0 mm)|
Transcaval case report (Figure 4)
Presentation of the transcava case (9). Available:http://www.asvide.com/article/view/24743
This is a frail 75-year-old woman with multiple comorbidities including chronic obstructive pulmonary disease, atrial fibrillation, history of stroke, coronary artery disease, peripheral artery disease, severe symptomatic aorta with disabling symptoms of heart failure. The patient was evaluated by the cardiac surgery team and considered high risk for surgical aortic valve replacement (30-day STS predicted mortality of 8.2%).
The patient's procedure was performed in the Oklahoma Heart Institute's Hybrid Cardiac Catheterization Laboratory. The transcava technique was previously described in detail (10). The methodology for interpreting a CT scan for transcaval TAVI planning has also been previously described in detail (5). Standard pre-procedure TAVR planning CT scan is analyzed to determine an appropriate preselected target site for passage of the inferior vena cava to the abdominal aorta (Figura 5A).
Standard steps for the transcava TAVR procedure. (A) TC plane with yellow arrows showing the proper target to pass; (B) Aortogram/cavagram; (C) passage of electrified wire to the aortic loop; (D) TAVR sheath placement from the femoral vein to the aorta; (E) Final closure of the aortocaval pathway with an ADO-1 plug.
The anesthesiologist administered moderate/conscious sedation. Bilateral percutaneous femoral arterial and venous access was obtained using the modified Seldinger technique. Baseline simultaneous aortogram and vena cava were performed to assess anatomy and correlate with preprocedure CT findings (Figure 5B). A crossover catheter was placed in the inferior vena cava and a swan neck sling at the predetermined passage site was placed in the aorta. Next, a 0.014” diameter motorized guidewire was passed from the vena cava to the aorta and captured with the snare, thus creating the aortic conduit of the horse (Figure 5C). Then, through this horse aortic tract, the transcatheter heart valve sheath (Edwards Lifesciences eSheath 14F) used to position the heart valve was advanced from the IVC into the aorta (Figure 5D). Once in the aorta, the patient's iliofemoral arteries that were unsuitable for transfemoral access were bypassed and an Edwards SAPIEN 3 26mm transcatheter heart valve was implanted using the standard technique from a standard retrograde aortic approach.
After successful transcatheter aortic valve placement, the horse's aortic tract was closed using a nitinol occluder device (10/8 mm Amplatzer Duct Occluder, Abbott). The occluder device is used to close the opening in the side wall of the aorta, this is done when the large release sheath is removed from the aorta. Aortic closure was then evaluated with angiography. Initially, angiography demonstrated an aortocaval shunt and mild retroperitoneal bleeding. Given these findings, adjuvant balloon angioplasty of the infrarenal abdominal aorta (Atlas Gold 10 mm × 40 mm balloon, Bard) was performed simultaneously with recontainment and slight repositioning of the OAD device, so that it was more perpendicular to the cauda aortic tract with the disc. of the device parallel to the aortic wall. It is not uncommon to have a persistent aortocaval shunt immediately after the procedure. This is considered acceptable unless there is bleeding into the retroperitoneal space or the aortocaval shunt is causing heart failure (7,8).
CT of the abdomen and pelvis was performed on day 1 after the procedure and demonstrated the absence of residual aortocaval shunt and retroperitoneal bleeding (Figure 5E). The study findings demonstrate that 36% of aortocaval fistulas closed immediately after transcaval TAVI, 53% closed at hospital discharge, and 64% of fistulas closed within 30 days (8).
The patient was monitored in the cardiovascular unit after the procedure and got out of bed later that day. The patient did well during hospitalization and was discharged the second day after the procedure. Control angio-CT of the abdomen and pelvis was performed 1 month and 1 year after the procedure. Both studies demonstrated that the closure device was in good position, with no aortocaval shunt, aortic pseudoaneurysm, or other abnormality at the cava-aortic tract site. The patient is now over a year post transcaval TAVR and is doing very well with no symptoms of congestive heart failure with normal function of her prosthetic aortic valve.
To date, approximately 450 transcava TAVR procedures have been performed worldwide and this approach is a safe and effective option for patients who are not candidates for transfemoral TAVR and standard thoracic alternative access TAVR. As described above, transcaval access and closure for TAVR are standardized and reproducible, and overall the approach is safe and effective for high-risk patients with limited options for TAVR. Continuous follow-up of patients treated with this approach and future studies will help us to determine the long-term results of this technique, mainly in relation to transcaval access.
expressions of gratitude
Informed consent:Written informed consent was obtained from the patient for publication of this manuscript and accompanying images.
Conflicts of interest:The authors have no conflict of interest to declare.
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articles ofJournal of Visualized Surgeryare provided here courtesy ofAME publications
What is the most common complication of TAVR? ›
Conduction abnormalities requiring permanent pacemaker (PPM) implantation and development of new left bundle branch block (LBBB) remain the most common TAVR complications.What should I look for in a post TAVR? ›
- Shorter Time in the Hospital. Work with New Jersey Cardiology Associates to plan out your goals for recovery. ...
- There Will Be Pain. There will be some pain at the catheter insertion site. ...
- You Will Need Cardiac Rehab. ...
- Expect A Gradual Return To Your Activities. ...
- New Meds. ...
- Watch For Complications.
“There is no question that TAVR is the treatment of choice in the extreme-risk patient who cannot have surgery,” said Martin B. Leon, MD, FACC, during an ACC. 17 session on TAVR. “Their median life expectancy will be increased from 11 months to almost 30 months with TAVR.”What percent of TAVR cases result in stroke? ›
Following initial experience with TAVR, various studies reported a range of stroke of 0–3.9% vs. 0.5%–5.7% with SAVR. Similarly, according to published registries, the overall incidence rate of stroke in high-risk patients after TAVR varied from 1.7% to 4.8%.What is the downside of TAVR? ›
Stroke: A small percentage of people undergoing TAVR have developed a stroke, either during the procedure or in the days immediately following it. Death: While TAVR is an effective and often much-needed treatment for sicker people, they face a very low possibility of not surviving the procedure.What are the big 5 TAVR complications? ›
- Post-TAVI aortic regurgitation. Paravalvular regurgitation. Central regurgitation.
- Valve thrombosis.
- Valve obstruction.
- Late bleeding.
- Prosthetic valve endocarditis.
Every patient's recovery process is unique, but a typical recovery time following TAVR is 1-2 weeks. Your individual medical condition plays a big factor in the recovery process. There are also things you can do before and after surgery to aid in the process.How long does fatigue last after TAVR? ›
At first you may notice that you get tired easily and need to rest often. It may take 1 to 2 months to get your energy back.How often does TAVR fail? ›
Early experience suggests that cannulation of the coronary arteries following redo-TAVR can be unfeasible in up to 30% of patients depending on the type of index TAVR valve. The risks appear higher in those with a supra-annular THV compared with annular valves.Can you live 10 years after TAVR? ›
Medical literature suggests the lifespan of the tissue valves used in surgical aortic valve replacement is typically about 10 to 20 years. Since TAVR valves are made of the same biological tissue, it is expected they will have the same longevity.
Can you live 20 years after aortic valve replacement? ›
Pooled data from 85 studies estimated that 89.7% of people survived for two years after surgery, 78.4% at five years, 57.0% at 10 years, 39.7% at 15 years, and 24.7% at 20 years. Subgroup analysis showed that five-year survival declined with increasing patient age (from 83.7% in under-65s to 52.5% for those over 85).Can you live a normal life after TAVR? ›
There is research that shows patients who undergo TAVR have reduction in symptoms, improvement in ability to take care of themselves, improved heart function, and improvement in overall quality of life at 30 days. Most patients are able to return to work within two weeks after the procedure.What is one year mortality after TAVR? ›
Conclusions: In a national sample of TAVR patients, readily available information on age and comorbidities, can be used to identify a high-risk group with 25 % 1-year mortality.What is the 30 day mortality rate for TAVR? ›
Conclusions: We identified 30-day all-cause mortality rate for TAVR of 2.2%. Approximately one-third of patients experienced out-of-hospital mortality at 30 days. Several factors were identified as being independently associated with 30-day out-of-hospital all-cause and cardiovascular mortality.What causes mortality after TAVR? ›
Within 30 days of TAVR, infection/sepsis (18.5%), heart failure (14.7%), and multiorgan failure (13.2%) were the top 3 causes of death. Beyond 30 days, infection/sepsis (14.3%), heart failure (14.1%), and sudden death (10.8%) were the most common causes. All possible subgroup analyses were made.Why is my vision blurry after TAVR? ›
blurred vision/dots in front of the eyes: This can be due to the contrast media used by the doctor during the procedure but should resolve shortly after the procedure. If it does not, please contact the TAVI nurse.Is TAVR riskier than open heart surgery? ›
The rate of aortic valve reintervention over 5 years was 3.2% for TAVR patients compared to 0.8% with surgery. Nonetheless, reintervention with TAVR was associated with lower mortality than surgery.Why is TAVR only for high risk patients? ›
One reason TAVR is currently restricted to patients at higher risk is that it's a pretty new procedure, so we don't have established data for how it compares over the long term to traditional surgery. One of the questions up in the air surrounds the durability of the valves used in TAVR.How long does it take to recover from a Tavr heart valve replacement? ›
TAVR recovery is much faster than recovery from open-heart surgery, and most patients can resume normal activities within two weeks.What percentage of TAVR patients need a pacemaker? ›
TAVR and surgical aortic valve replacement (SAVR) are the only treatment options for patients with severe aortic valve stenosis. However, the prevalence of permanent pacemaker implantation after TAVR ranges from 9% to 26% (1-4).
What happens to the old valve in TAVR? ›
In conventional open-heart surgery, when the aortic valve is replaced, the old valve is removed, and a new valve sewn into place. In the TAVR procedure, the new valve is simply placed inside the existing valve, crushing it out the way.How do people feel after a TAVR? ›
PAIN AND DISCOMFORT
If you had a transfemoral or transcaval TAVR through the groin, you may have pain in the groin. You may also develop a large bruise that will likely last for weeks but will go away with time. If you had a transapical or transaortic TAVR through the chest wall, you may have pain in the chest area.
Daily activity and exercise are an important part of your recovery. People recover at different rates depending on their general health and type of procedure. Cardiac Rehabilitation may be scheduled while you are in the hospital or may receive a scheduling call after discharge.What major surgery is done after TAVR? ›
TAVR recipients most commonly underwent subsequent neurological or orthopedic major surgery (32.7%), followed by superficial (15.7%) and intraperitoneal surgery (13.7%). Thirty-day outcomes after surgery included death in 9.6%, and bleeding in 11.3%.How long are you on blood thinners after TAVR? ›
Expert consensus guidelines recommend dual antiplatelet therapy (DAPT) for 3 up to 6 months after TAVR.Will I have more energy after aortic valve replacement? ›
When you are 6 months past your aortic valve replacement, you should be able to resume most, if not all, the activities you enjoyed before your procedure. You may even find that you have more energy and feel better than you did 6 months ago.What happens to blood pressure after TAVR? ›
In their study of 105 consecutive patients after TAVR, 51% had sustained increases in BP after TAVR, requiring intensification of antihypertensive treatment. Patients with increased BP had an increase in stroke volume and cardiac output independent of other factors and, thereafter, a better prognosis.Does the heart stop during TAVR? ›
During SAVR, a surgeon will cut through your chest and breastbone to reach your heart. They'll also need to use a cardiopulmonary bypass machine to temporarily stop your heart so they can access the aortic valve within the heart. The TAVR procedure is much less invasive and doesn't require stopping the heart.Is heart failure common after TAVR? ›
Readmission for heart failure (HF) occurs in as many as 25% of patients within the first year following transcatheter aortic valve replacement (TAVR).How often should you see a cardiologist after aortic valve replacement? ›
You will need to see your cardiologist six to eight weeks after the surgery to determine how well you are healing. At this appointment, your doctor will give you instructions on driving, returning to work, and medications. Then, your doctor will tell you how often you should return.
What is the best aortic valve replacement? ›
TAVR, or Transcatheter Aortic Valve Replacement, is quickly becoming the new gold-standard for treating people suffering from aortic valve disease.Can you live a full life after aortic valve replacement? ›
Data suggests that at 10 years after surgery, 1 in 5 patients who undergoes a mechanical aortic valve replacement at 50 years of age has died or required a reoperation.What is the quality of life after a TAVI? ›
Conclusions. TAVI is associated with significant early improvement in QOL, which is sustained at 1 year. The inclusion of QOL can support treatment decisions and patient-centred evaluation.What is the gold standard for TAVR? ›
Femoral access is the gold standard for transcatheter aortic valve replacement (TAVR).Do you go to ICU after TAVR? ›
Most patients stay in the ICU for 1 to 2 nights after TAVR. How long you stay in the ICU depends on how your recovery is going. Your time in the ICU is when the most important changes in your condition occur. Highly-skilled nurses will monitor and care for you in the Intensive Care Unit after your surgery.Who is considered high risk for TAVR? ›
Your doctor may recommend TAVR if you have: Severe aortic stenosis that causes signs and symptoms. A biological tissue aortic valve that isn't working as well as it should. Another health condition, such as lung or kidney disease, that makes open-heart valve replacement surgery too risky.