Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.
Transcatheter aortic valve implantation (TAVI) has now become the default intervention for severe, symptomatic aortic stenosis (AS) in inoperable and high-risk patients and patients at intermediate risk who are anatomically suitable for the transfemoral approach, under the guidance of a multidisciplinary heart team. Evidence is building for the use of TAVI in low-risk patients and as a result, the number of TAVI procedures in all developed nations is increasing dramatically. The number of TAVI procedures exceeded the number of isolated surgical aortic valve replacements in the US in 2015 and all surgical aortic valve replacements in 2018 according to the latest Transcatheter Valve Therapy Registry data. 1 Although the UK is lagging behind most of these nations, the numbers of TAVI procedures is nevertheless increasing year by year.The British Cardiovascular Intervention Society (BCIS) has issued guidance as to how patients with AS should be managed and a service specification as to how TAVI should be performed. 2 We hope this will go some way to standardising care across the UK for patients with AS but we are aware that much more needs to be done. BCIS is collaborating with the Valve for Life campaign to analyse inequities in TAVI provision in the UK and we hope to work with NHS commissioners to address this, and to encourage new centres to provide TAVI where local provision is inadequate or impossible with current facilities. The following document forms the basis of what will be a prolonged effort to improve TAVI provision in the UK and standardise its delivery.
Severe aortic stenosis patients with bicuspid anatomy have been excluded from the major transcatheter aortic valve replacement (TAVI) randomized clinical trials. As a result, there is no official recommendation on bicuspid TAVI. A panel of bicuspid experts was created to fill this gap. In this consensus statement, an algorithm is proposed to guide the choice of surgery or TAVI within this complex patient population, depending on aortic dilatation, age, surgical risk score, and anatomy. A step-by-step guide for sizing and positioning of the SAPIEN 3/Ultra TAVI bioprostheses is presented. Annular sizing remains the primary strategy in most bicuspid patients. However, some anatomies may require sizing at the supra-annular level, for which patients the panel recommends the circle method, a dedicated sizing and positioning approach for SAPIEN 3/Ultra. The consensus provides valuable pre-operative insights on the interactions between SAPIEN 3/Ultra and the bicuspid anatomy; understanding the valve-anatomy relationship is critical to avoid
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