TAVR (Transcatheter Aortic Valve Replacement)

Catheter-based replacement of the aortic valve in patients with severe aortic stenosis. One of the largest changes in cardiovascular medicine over the past decade — TAVR has steadily expanded from high-risk-only (PARTNER 1, 2010) to intermediate-risk (PARTNER 2, 2016) and now low-surgical-risk indications (PARTNER 3 / Evolut Low Risk, 2019). Two valve platforms dominate: balloon-expandable Edwards SAPIEN and self-expanding Medtronic Evolut.

Clinical workflow

Pre-procedure CT — contrast-enhanced ECG-gated cardiac CT measures aortic annulus, coronary heights, access vessels (iliofemoral runoff). Dedicated 64-slice-class CT essential; cardiac + peripheral runoff in one exam.
Heart Team evaluation — interventional cardiology + cardiothoracic surgery + cardiac imaging + anesthesia review pre-procedure.
Access — transfemoral default (>95% of cases); alternative access (transcaval, transapical, transaortic, subclavian, carotid) less frequent.
Valve deployment — balloon-expandable (Edwards SAPIEN 3 / Ultra) or self-expanding (Medtronic Evolut PRO+ / FX) under fluoroscopic + TEE guidance.
Post-deployment assessment — paravalvular leak evaluation, hemodynamics, coronary patency, final angiography.

Typical imaging systems

Cardiac CT (pre-procedure):

SOMATOM Definition Flash — dual-source cardiac CT.
SOMATOM Force
Revolution Apex — wide-detector cardiac CT.
Aquilion ONE — wide-detector cardiac CT.

Fluoroscopy (procedure) — biplane cath lab or hybrid OR:

Allura Biplane
Azurion 7
Artis pheno — robotic floor-mounted, common in TAVR programs.
Artis zee / Artis Q

TEE (procedure):

Philips iE33
Philips EPIQ CVx
GE Vivid E9 / Vivid E95 with 3D TEE probe

Room requirements

Hybrid OR or biplane cath lab. Sterile OR-grade environment with full cath-lab imaging capability. Perfusion team, anesthesiology, cardiothoracic backup, TEE, hemodynamics. Multi-disciplinary Heart Team evaluation before every case.

Procedure characteristics

Room time: 2–4 hours.
Fluoroscopy time: 15–45 min (variable with complexity).
Length of stay: 1–3 days for most patients; same-day discharge selected low-risk cases (especially conscious-sedation transfemoral with minimal complications).
Valve-in-valve: increasingly used for degenerated surgical valves.

Equipment considerations that bite

Imaging quality matters at sub-mm scale — small annulus measurement errors (~1 mm) change valve sizing decisions. CT protocol standardization + reader experience affect outcomes.
Hybrid OR build-out — sterile-OR plumbing + cath-lab imaging chain is a multi-million-dollar build. Conversion of existing OR or cath lab is a major capital project.
3D TEE probe is the imaging-side enabler; older 2D-TEE-only platforms run TAVR but at clinical-quality compromise.
Dose-management software — long-fluoro cases push patient and operator dose; ClarityIQ / CARE / AutoEx materially shift career-cumulative exposure.
Robotic gantry (Artis pheno) or FlexArm Azurion — larger working envelope around the patient is operationally favorable in a hybrid suite.
Drape kit + sterile workflow — TAVR-specific drape inventory; missing drapes stop a case.

Operational reality

Heart Team is structural — TAVR programs are organized around multi-disciplinary case selection, not the equipment alone.
Volume concentration — TAVR is concentrated at programs with cardiothoracic surgery backup; community-hospital TAVR programs typically partner with referring tertiary centers.
Competing technologies — TAVR has replaced surgical AVR for most non-bicuspid severe AS in operable patients. Adjacent transcatheter mitral / tricuspid valve devices (MitraClip, Tendyne, EVOQUE) are growing.
Refurb economics — biplane installs and hybrid-OR-suitable platforms (FlexArm, pheno) carry meaningful capital premium.