CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 AFRICA 269 Contra-indications • Absence of MDT and no cardiac surgery on site. • Patients whose life-expectancy is less than one year. • Predicted lack of clinical improvement after TAVI due to co-morbidities. While it can be difficult to discern to what extent AS is contributing to a patient’s symptoms as opposed to underlying co-morbidities, it is important to carefully assess this, to avoid a futile TAVI procedure. • Anatomical factors: – Unsuitable annulus size – Active endocarditis – Inadequate vascular access. • Significant other valve lesions. • Relative contra-indications: – LV ejection fraction < 20% – Haemodynamic instability – Presence of coronary artery disease that requires coronary artery bypass graft. Cost-effectiveness studies for TAVI Numerous cost-effectiveness studies in various clinical environments have shown that TAVI is cost effective with a better yield in terms of cost per quality-of-life years gained compared to sAVR.12-15 This is particularly the case if the procedure is performed under local anaesthetic via the transfemoral approach with a short hospital length of stay. Conclusion TAVI has become the established therapy for severe AS in patients with technical contra-indications for sAVR, frail patients, patients with significant co-morbidity and patients at high and intermediate surgical risk. Recent evidence supports TAVI in older low-risk patients. Concerns regarding the long-term structural integrity of transcatheter valves remain, although there is no signal to date that the outcomes are any worse compared to sAVR with a bioprosthesis. The decision regarding the choice of aortic valve intervention and/or medical therapy alone should be individualised and must be made by the MDT after weighing up all factors that affect the short-, medium- and long-term outcome of a patient with symptomatic severe AS. References 1. Scherman J, Weich H. SASCI/SCTSSA joint consensus statement and guidelines on transcatheter aortic valve implantation (TAVI) in South Africa. Cardiovasc J Afr 2016; 27(6): 399–400. 2. Alkhalil A, Lamba H, Deo S, Bezerra HG, Patel SM, Markowitz A, et al. Safety of shorter length of hospital stay for patients undergoing minimalist transcatheter aortic valve replacement. Catheter Cardiovasc Intervent 2018; 91(2): 345–353. 3. 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