Ibrahim Akin, Stephan Kische, Tim C. Rehders, Christoph A. Nienaber, Mathias Rauchhaus, Hüseyin Ince, Henrik Schneider, Andreas Liebold Analysis of surgery risk and evaluation of life expectancy and quality of life The precise evaluation of surgical risk in a specific patient is not easy and involves an attempt at individualisation based on statistical data from databases containing a large number of procedures. The most accepted and validated algorithms that are widely available today are the EuroSCORE, the STS (Society of Thoracic Score) and the Parsonnet score. These algorithms predict the surgical risk by assigning weight to various factors that affect the clinical result, but it is clear that they can underestimate or overestimate it in certain groups of patients who are not represented satisfactorily in the population used to generate the algorithm [7]. There is some evidence in the literature of incorrect prediction of aortic valve replacement outcome using the EuroSCORE model [8]. Osswald et al. report on the real risk of overestimation of death by EuroSCORE for patients undergoing isolated aortic valve replacement, highlighting a possible incorrect assignment of high-risk patients to the PAVI procedure [9]. The key element to establish whether patients are at high risk for surgery is multi- disciplinary clinical judgement, which should be used in association with a more quantitative assessment, based on the combination of several scores (for example expected mortality > 20% with the EuroSCORE and > 10% with STS score). This approach allows the team to take into account risk factors that are not covered in scores but often seen in practice such as chest radiation, previous aorto- coronary bypass with patent grafts, porcelain aorta, liver cirrhosis, etc. Assessment of feasibility and exclusion of contraindications for percutaneous aortic valve implantation After criteria of severe symptomatic aortic valve stenosis and high surgical risk are evaluated, the technical evaluation of the patient’s suitability for the percutaneous implantation technique begins (Table I). The two most basic parameters are the suitability of the peripheral arteries and the size of the aortic valve annulus. Contrast angiography is needed to assess the former, while the latter requires an initial assessment of the diameter of the aortic annulus on a TTE. In general terms, a large artery with dominant elastic elements should have a diameter up to 1 mm smaller than the external diameter of the sheath that has to be introduced for the valve implantation. Thus, current systems with an external sheath diameter of 28 F (SAPIEN 26 mm, Edwards), 25 F (SAPIEN 23 mm, Edwards) and 22 F (CoreValve, Medtronic) require minimum diameters in the order of 8 mm, 7 mm and 6 mm, respectively. Apart from the minimum diameter, the existence of significant vessel Table I. Currently proposed indications and contraindications for percutaneous aortic valve implantation Indication for percutaneous aortic valve implantation Severe aortic stenosis (AVA: < 1 cm2, mean gradient > 40 mmHg, severe symptoms) Contraindication for surgical valve replacement Contraindication for percutaneous aortic valve implantation Mild to moderate aortic stenosis Asymptomatic patients Life expectancy < 1 year Surgical aortic valve replacement possible, but patient refused Aortic anulus < 18 mm or > 25 mm (balloon-expandable) and < 20 mm or > 27 mm (self-expandable) Bicuspid/unicuspid aortic valve Asymetric heavy valvular calcification Aortic root > 45 mm at the aorto-tubular junction Presence of left ventricular apical thrombus Contraindication for transfemoral approach Severe calcification, tortuosity, small diameter of the iliac arteries Previous aorto-femoral bypass Severe angulation, severe atheroma of the aorta Coarctation of the aorta Aneurysm of the aorta with protruding mural thrombus Contraindication for transapical approach Previous surgery of the left ventricle using a patch Calcified pericardium Severe respiratory insufficiency Non-reachable left ventricular apex 298 Arch Med Sci 3, June / 2010