Minimalist Approach to Evaluating Patients for Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has become an alternative to cardiac surgery in a growing number of patients. Initially oriented to those considered high-risk or inoperable, TAVR is rapidly extending toward lower risk populations.1 It may not be long until most patients with severe aortic stenosis (AS) will be treated by a transcatheter approach. Undoubtedly, in this rapidly changing field, periprocedural management will also evolve.See Article by Chieffo et al There is growing interest in performing TAVR using a minimalist approach.2 A reduction in the size of sheaths and improved delivery systems enable safer device transfer via the femoral artery in the vast majority of patients. Increasingly, centers perform TAVR in a conventional cath-laboratory setting, under conscious sedation, and without transesophageal echocardiogram monitoring.3 In addition, early patient discharge has become a reality.4 In our facility, many TAVR patients are discharged the next day, as part of a 3M protocol (Multidisciplinary, Multimodality, but Minimalist Approach). Remarkably, an anecdotal report of successful same-day discharge was recently described at another center.5In this new era of high-volume TAVR procedures and long waiting lists, there is a need for a more efficient system for patient assessment. The majority of centers regularly evaluate candidates for TAVR in the cath-laboratory by performing coronary angiography with the addition of aortic root and ileofemoral assessment. In the early days of TAVR, a combination of echocardiography and invasive angiography was the foundation of patient assessment and further evaluations, such as computed tomography (CT), were ordered as needed.The dramatic growing importance of CT angiography in TAVR is fascinating. In the original trials, cardiac CT was not requested.6 The main reason for performing CT in those early days was to assess the ability of the ileofemoral vessels to accommodate large caliber sheaths. The …