AORTIC STENOSIS &�TRANSCATHETER AORTIC VALVE REPLACEMENT

THE LEAFLET LOUNGE

KRISTINA MACK MSN-ED, BSN, RN, CCRN-CMC, CV-BC

UPDATED SEPTEMBER 2026

�DISCLAIMER��

The information in this presentation is for educational use only. For more details and updates on the devices pictured or mentioned within the text, please see their official website.

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Aortic Valve

Characteristics of a Normal Aortic Valve

• Semilunar valve that separates the left ventricular outflow tract (LVOT) from the aortic root
• Made of three fibrous leaflets (Tricuspid)
• Consists of the left coronary, right coronary, and non-coronary cusp
• Attached to a ring-like fibrous base called an annulus
• The commissures are the junction where adjacent cusps meet and attach to the aortic wall.
• The conduction system generally resides just below the right coronary cusp
• Opens passively when left ventricular pressure is higher than aortic pressure (systole)
• Closes during relaxation of the left ventricle (diastole)
• Forward, unidirectional flow

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(Golla et al., 2026)

Image from the American Physiological Society Journal

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Image from AnatomyTool.com

Image from Study.com

Aortic Stenosis

Aortic Stenosis

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Image from HeartValveSurgery.com

(Medtronic Academy, 2026)

Degenerative Aortic Stenosis

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(Medtronic Academy, 2026)

Congenital Aortic Stenosis

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(Medtronic Academy, 2026)

Rheumatic Aortic Stenosis

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(Medtronic Academy, 2026)

Epidemiology

• Primarily occurs in the elderly.
• Prevalence of AS will increase with age.
• Narrowing of the aortic valve creates an outflow obstruction that forces the left ventricle to work harder to overcome the increased pressure.
• Overtime the myocardial overload causes left ventricular thickening, stiffening, and eventual failure to supply enough blood and oxygen to support the body.

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SYMPTOMS�Patients may complain of chest pain, dizziness, lightheadedness, dyspnea, shortness of breath, exercise intolerance, and palpitations. Syncope, angina, and heart failure form the classic “SAD” triad associated with severe aortic stenosis. ���SYNCOPE – ANGINA - DYSPNEA

Symptom: Heart Failure

As discussed before, AS causes an insufficient pump leading to the inability of the heart to maintain blood flow to meet physiologic needs. AS is not only a disease of the valve itself because of its effect on the myocardium as well.

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Heart failure can be systolic or diastolic.

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The narrowed valve causes an increased pressure gradient. With afterload increasing, the left ventricle must work harder to overcome the resistance.

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Over time the left ventricle begins to stiffen and thicken (concentric LV hypertrophy). As this remodeling occurs, passive filling is slowed, and the diastolic function becomes impaired.

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With the increased afterload and decreased cardiac output, patients will develop atrial and pulmonary vascular remodeling leading to RV strain and pulmonary congestion.

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(Medtronic Academy, 2026)

NYHA Heart Failure Classifications

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(Brown et al., 2022)

Symptom: Syncope

• Syncope in AS is a serious warning sign causing transient loss of consciousness and postural tone with spontaneous recovery due to decreased cerebral blood flow (Grossman & Badireddy, 2023).
• Syncope associated with AS usually occurs during exercise but can be from dangerous ventricular rhythms and abnormal blood pressure reflexes. During exercise, peripheral blood vessels dilate. In patients with AS, the heart is unable to pump extra blood through the narrow valve and BP will sharply drop (Francisco-Pascual et al., 2021).
• An underfilled and hypercontractile ventricle can trigger mechanoreceptors within the ventricular wall causing sudden bradycardia, vasodilation, and low blood pressure leading to fainting. This is known as the Bezold-Jarisch Reflex (Dvoulety & Sitina, 2026).
• Arrythmias may occur due to the thickened wall which further worsens the pumping action and can lead to syncope.

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Symptom: Angina

• Angina is chest pain due to ischemia.
• The main cause of angina is coronary artery disease due to atherosclerosis.
• The same symptoms that cause chest pain can also be caused by AS.
• Symptoms of angina are chest pressure, heaviness, tightness, squeezing, and burning or choking sensation.

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Tests that confirm diagnosis of AS:

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Basic Assessment of Severity���

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The fundamental hemodynamic parameters that are used in evaluating the severity of AS are:

• Peak velocity of the AS jet and mean transvalvular pressure gradient
• Peak jet velocity is the highest systolic anterograde velocity through the stenotic aortic valve.
• Mean transvalvular pressure gradient is the average pressure difference, during systole, of the left ventricle and the aorta.
• Both measurements are flow-dependent and influenced by transaortic flow
• Effective aortic valve area (AVA) using the continuity equation.
• AVA remains stable so it is a more reliable measure of severity compared to peak velocity and mean transvalvular pressure gradient.
• The continuity equation determines severity by calculated the AVA using the left ventricular outflow tract (LVOT) area, LVOT velocity, and aortic valve velocity.

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(Rizzello, 2021)

Aortic Stenosis Severity Grading

Image from Research Gate

(Rana, 2022)

Aortic Stenosis Staging

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(Clavel et al., 2017)

What is TAVR?

• TAVR stands for transcatheter aortic valve replacement.
• It may also be called TAVI (transcatheter aortic valve implantation).
• TAVR is a less invasive alternative to open-heart surgery (SAVR).
• TAVR is a minimally invasive treatment for severe aortic valve stenosis (AS), failing biological valve, and in some cases, aortic regurgitation.

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Image from Oxford Academic

Indications for TAVR

Indication for TAVR: Aortic Stenosis

• Symptomatic AS
• Symptomatic AS with severe high-gradient
• Symptomatic AS with low-flow, low-gradient with reduced LVEF
• Symptomatic AS with low-flow, low-gradient with normal LVEF
• Asymptomatic AS
• Severe AS with LVEF < 50% and no other cause
• Severe AS with a sustained drop in BP (>20 mmHg) during exercise test
• Very severe AS with mean gradient ≥ 60 mmHg and peak velocity >5.0 m/s
• Rapidly progressive AS with peak velocity increasing ≥ 0.3 m/s per year and severe calcification
• Markedly elevated BNP

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(Golla et al., 2026)

Indication for TAVR: Aortic Regurgitation

• Most patients with severe AR are treated surgically, but TAVR is an emerging approach for patients that are high risk and not surgical candidates.
• The American Heart Association (AHA) defines severity of Aortic Regurgitation as:
• Jet width ≥65% of the LVOT diameter
• Vena Contracta (measures narrowest neck of leaking valve) > 0.6 cm
• Regurgitant volume ≥ 60 mL per beat
• Regurgitation fraction ≥50%
• Effective regurgitant orifice area ≥0.3 cm2
• The biggest challenge of using TAVR for severe AR treatment is the lack of calcium to anchor the device which can lead to device embolization. Additionally, the aortic annulus is large with a dynamic size.
• Not all devices are approved for use in severe AR.

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(Aortic Valve, 2025)

Indication for TAVR: Bicuspid Aortic Valve Dysfunction (BAV)

• As stated before, patients born with a BAV are more susceptible to the development of AS.
• Provided the anatomy is suitable for a prosthesis valve, TAVR may be considered for the treatment of severe BAV dysfunction in patients that have increased surgical risk.

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(Golla et al., 2026)

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Contraindications for TAVR

• TAVR is generally contraindicated in patients with life expectancy less than 1 year due to significant comorbidities and noncardiac diagnoses.
• TAVR is often preferred over SAVR in patients with mild-to-moderate frailty
• Patients with severe or critical frailty TAVR can be considered a contraindication if having the procedure is unlikely to provide improved survival or functional status.
• Additional contraindications include:
• Active endocarditis with vegetation
• Presence of an intracardiac mass or thrombus
• Recent MI within 30 days
• Hemodynamic or clinical instability requiring emergent surgery
• EF <20%
• TAVR may be contraindicated due to anatomical limitations such as incompatible annulus size, excessive or bulky calcifications of the annulus and/ or LVOT, short coronary heights (especially with shallow sinuses of Valsalva), and vascular access anatomy that can limit procedure practicability.
• Younger patients with low surgical risk are better candidates for SAVR over TAVR
• Patients with BAV, as well as aortic disorders, often favor SAVR vs. TAVR.

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(Hadi Mahmaljy et al., 2023)

Pre-Procedure Considerations

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The Structural Heart Coordinator, pre-assessment team, scheduling, radiology, cardiopulmonary, blood bank, lab, department coordinators, and MD offices will work closely together to prepare patients for their TAVR date.

Patients will have a specific work-up to be completed and include:

• Initial contact with Structural Heart Coordinator
• Interventional Cardiologist Consult and/or CV Surgeon Consult
• Each must have privileges with the hospital
• Joint participation of two TAVR operators in a TAVR procedure is no longer required (As of September 10, 2026), but it is covered if determined appropriate by the heart team.
• Eligibility Form signed by CV Surgeon and Structural Heart Coordinator after Heart Team Evaluation to determine TAVR vs. SAVR
• Frailty testing with 5 meter walk test
• Kansas City Cardiomyopathy Questionnaire (measures patient’s symptom burden to assess prognosis risk and functional capacity)
• NYHA Heart Failure Classification
• TAVR CT and CTA chest/ abdomen/ pelvis
• EKG (within 14 days of procedure)
• Labs (within 14 days of procedure): CBC, CMP, liver panel, albumin, BNP, plasma free hemoglobin, PTT/ PT/ INR, CK/ CKMB/ Troponin, and type & screen
• Blood Bank: type & crossmatch two units of PRBCs for day of procedure (will be in the room ready for procedure)
• Left and/ or right heart catheterization (within 1 year of procedure)
• ECHO (TEE or TTE)
• Chest x-ray, bilateral carotid ultrasound, PFTs with DLCO, and dental clearance as needed
• Heart Team Shared Decision meeting
• The Heart Team Shared Decision Council will analyze the workup performed to determine if the patient is a SAVR, TAVR, or palliative care candidate.
• The following image, provided by the American Heart Association, is the workflow to assist with determination of procedure type or palliative care.

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Patients will be scheduled as Surgery Admit class and admitted as Inpatient to CVICU post-procedure.

Patients will be consented for:

• Transcatheter Aortic Valve Replacement and all indicated procedures.
• 2 a - use of blood and/or blood products
• 15 h - procedures utilizing prolonged fluoroscopy
• 21 I e - percutaneous or minimally invasive heart valve insertion/ replacement
• 21 II b - angiography injection of contrast material into blood vessels
• Consent for General Anesthesia
• These cases will be performed under general anesthesia (GA) or monitored anesthesia care (MAC)

TAVR Procedure

Team Players

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• Interventional Cardiologist
• Cardiovascular Surgeon
• Anesthesia Services
• Perfusionist
• Echocardiogram Technician
• Device Rep
• Cath lab scrub tech
• CVOR scrub tech
• Cath lab registered nurse
• CVOR registered nurse
• Person monitoring the case

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Pre-Procedure

• CV Surgeon Consult
• Interventional Cardiologist Consult
• Functional Assessment Tool
• Kansas City Cardiomyopathy Questionnaire
• STS Calculation
• High Risk ≥ 8%
• Moderate Risk 3 – 8%
• Low Risk ≤ 3%
• EKG and Labs within 14 days of procedure
• CBC with diff, CMP, albumin, BNP, plasma free hemoglobin, PTT/ PT/ INR, CK/ CKMB/ Troponin, and type and screen for 2 units of PRBCs on hold for procedure
• ECHO within 45 days (TTE or TEE)
• TAVR CTA and CTA Chest/ Abdomen/ Pelvis
• Pulmonary Function Tests (PFTs) and Carotid Duplex (as needed)
• H&P within 30 days of the procedure
• Heart Team Evaluation via TAVR Conference

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Typically, 2-3 scrub tables will be made

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1. Endovascular table
2. Device setup table

3. May have third table ready as backup if patient needs emergent open-heart surgery due to complications of TAVR (Open table).

Intra-Procedure

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• TAVR is performed by an interventional cardiologist.
• The procedure can be performed using MAC or general anesthesia, dependent on preference and risk assessment.
• Vascular access is obtained using femoral, subclavian, carotid, transaortic, or transapical approach.
• Venous access for temporary pacemaker
• Arterial access for device placement
• Second arterial access for Cerebral Protection System, if indicated
• Anticoagulation is administered during the procedure to obtain and maintain targeted activated clotting times.
• Pre and post balloon dilation is optional and dependent on calcification.
• The TAVR device may be balloon-expandable or self-expanding.

Image from Woodley Equipment

Image from Pfizer Hospital US

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• A temporary pacemaker will be placed for rapid ventricular pacing (RVP). This is performed during the procedure and used for precise deployment of the device.
• RVP is induced during balloon-expandable valve deployment (140-180 beats/minute)
• Frequently RVP is induced during self-expandable valve release or post-dilation to temporarily drop systemic pulse pressure and cardiac output.
• RVP minimizes device displacement
• RVP will reduce left ventricular stoke volume and dampen cardiac motion
• It prevents the forward ejection vector of blood in the high-pressure aortic annulus from displacing the bioprosthetic valve during deployment.
• Some patients may need a permanent pacemaker after TAVR.
• Self-expanding valves have a higher pacemaker rate.
• Pre-existing heart rhythm issues, such as conduction blocks or SSS, increase this risk.
• Patient anatomy may increase this risk.
• Bundle of His runs through area just below right and non-coronary cusps. Compression from the device in this area can trigger a heart block.
• Heavy valve and LVOT calcification just below the non-coronary and right coronary cusps forces the frame of the device to press unevenly against the heart muscle causing pressure that affects electrical pathways.

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Image from Medtronic

(Sharma and Sharma, 2019)

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• A cerebral embolic protection system may be placed.
• This is dependent on the patient’s calcium score and MD discretion.
• High calcium scores can increase the risk of procedural complications.
• Paravalvular leaks (PVL)
• Annular rupture
• Stroke
• The device has small polyurethane filters that catch loose tissue, calcium, and debris.
• 2 units of PRBCs must be present in the room with every case.
• Pre- and post-gradient measurements will be taken during the procedure.
• Dual transducer
• P1 = LV
• P2 = AO

Image from Boston Scientific

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The MD will use a suture-mediated closing device or figure-8 suture with a stopcock for closure. A radial artery compression device will be used for radial access removal, and a percutaneous vascular closure device will be used for the venous access. For transapical and transaortic access, pre-placed surgical purse-string sutures with felt pledgets are placed and tightly secured when the delivery system is removed.

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https://eurointervention.pcronline.com/article/tavi-transapical-what-else

https://eurointervention.pcronline.com/storage/issues/82nd_issue/231/medias/151187/01_Geis_fmt.jpeg

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https://tis.terumo.com/sites/g/files/qlpvch321/files/styles/free_crop/public/products/detail/products_detail_small_1_tr_band.png?itok=-NTvVpTU

Possible Complications

Although complications during TAVR are rare, they can still be life-threatening. It is important to understand what to watch for and how to intervene.

Possible complications include vascular and access-site complications, cardiac conduction disturbances, stroke, coronary obstruction, valve malposition or embolization, acute kidney injury, paravalvular leak, prosthesis-patient mismatch, valve thrombosis, valve deterioration, annular rupture, and arrhythmia (Hadi Mahmaljy et al., 2023).

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(Grube & Sinning, 2019)

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(Golla et al., 2026)

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(Golla et al., 2026)

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(Golla et al., 2026)

Post-Procedure

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• Patients will be admitted to the CVICU, downgrade to IMU if applicable.
• If beds are not available, the patient will go to cath lab recovery.
• Complete NIH Scale and vascular checks distal to access site.
• Q15 minutes x 4 (1 hour)
• Q30 minutes x 2 (1 hour)
• Q4 hours x18 hours and prior to discharge
• Glascow coma scale Q4 hours until discharge
• Follow radial compression device removal protocol.
• If sheath is still in place, perform vascular checks
• Q15 minutes x 4 (1 hour)
• Q30 minutes x 2 (1 hour)
• Q1 hour until removal
• Document vascular site assessment and documentation of post-sheath removal Q4 hours until discharge.
• Notify MD for bleeding, tenderness, and hematoma
• Remove arterial line if ACT <150, SBP >100 mmHg, and HR <100 bpm
• Cardiac monitoring and vital signs per order
• Strict I/O’s
• Labs, 12 lead EKG, and CXR per physician order

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• Expect patients to restart their daily antiplatelet and/or anticoagulation therapies as ordered
• Complete prophylactic antibiotics for 24-48 hours as ordered
• PUD/ stress ulcer prophylaxis if intubated
• Antihypertensives initiated per MD order
• Pain control as ordered
• Bowel regimen per order
• VAP and VEP Protocol if intubated with ventilator setting per intensivist; early extubation if possible.
• Titrate oxygen for SpO2 ≥90% and wean down to room air or baseline as tolerated
• Mobility
• Patients may have HOB up to 30⁰ after 2 hours if hemodynamically stable with no S&S of bleeding or hematoma at vascular access sites.
• Patients may get out of bed into the chair after 4 hours if hemodynamically stable with no S&S of bleeding or hematoma at vascular access sites.
• After 6 hours, patients may walk with assistance.
• Heart healthy diet and controlled carbohydrate diet for diabetic patients.
• All patients will have a cardiac rehab order. Speech therapy, spiritual care, PT/OT consults as needed. Case management will be consulted for discharge planning.

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Discharge Instructions

• Most patients will be discharged from the hospital in 1 – 2 days.
• Patients may return to normal light activities within a few days. Most patients achieve full recovery in 6 to 10 weeks.
• Instruct patients to not lift anything that weighs more than 10 pounds or push/pull heavy objects for the first 5 to 7 days after the procedure.
• Patients should not drive for at least one week or until cleared by physician. They may ride as passenger.
• Instruct patients to take their antiplatelets or anticoagulant as prescribed to prevent thrombus formation on their new valve.
• Patients will go to Cardiac Rehab to rebuild their strength.
• Instruct patients to follow the instructions given to them by Cardiac Rehab.
• They should walk 30-45min daily and may break the time into multiple trips per day.
• Notify patients that it is imperative to attend their follow-up visits.
• 1-2 weeks after procedure
• 30-day follow-up
• 1 year follow-up

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• Surgical Site Care:
• Keep access site clean and dry.
• Avoid submerging in a tub or pool for at least a month or until physician states it is okay.
• Patient may have some bruising or soreness at the site, this is normal.
• Remove any dressings from the surgical site and begin showering after 24 hours.
• Gently clean the site daily using gentle soap (i.e., Dial, Dove, Ivory). DO NOT scrub the incisions until sites are fully healed.
• Pat dry incisions with clean towel and leave open to air.
• DO NOT any use creams, lotions, powders, or ointments directly on the incision site.
• Dental work:
• No dental/ oral work until approved by the physician. Typically, this is up to six months.
• Instruct patients to postpone any dental cleaning during this time.
• In addition, the patient will need antibiotics prior to any dental procedure.
• Instruct patient to notify physician immediately with
• Temperature of 101 degrees or higher
• Weight gain of two pounds or more from one morning to the next
• Increased discomfort
• Redness, draining, swelling, increased warmth, and increased tenderness at the surgical sites.
• Recurrence of chest pain or shortness of breath.

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Resources

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Resources Continued

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Thank You

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