Current ACC/AHA guidelines recommend the use of a hybrid operating theatre for implantation of the transcatheter aortic valve, although at some centers, there has been a transition to procedural performance in appropriately outfitted catheterization laboratories. Current guidelines also mandate that both an interventional cardiologist and cardiothoracic surgeon be present for the procedure [1].

The preoperative evaluation is summarized in Fig. 34.3, and it is essentially congruent with a surgical evaluation with the addition of Multidetector Computed Tomography (MDCT). This modality is of particular importance for TAVR as it enables one to choose the appropriate device size based on aortic annular area/perimeter, evaluate left ventricular outflow tract and valvular calcification, assess coronary heights, sinus width, sinotubular junction diameters/calcification, angiographic views and potential access routes (Fig. 34.4). While many of these variables can be assessed through alternative modalities, MDCT is a singular, detailed and three-dimensional modality with dedicated software systems allowing for reliable and reproducible analyses and pre-TAVR planning.

Regarding access, the transfemoral route is generally favored for patients with suitable iliofemoral anatomy to accommodate currently available devices, and approximately 80 % of procedures are now performed via transfemoral access. For patients with iliofemoral disease precluding device delivery, alternative access routes are possible. These alternative sites include open iliac (via conduit), subclavian, direct aortic or transapical. Additionally, direct carotid or transcaval access (with crossover from the inferior vena cava to the aorta) may be of utility in appropriately selected patients.