Lifetime Management of Aortic Stenosis: Transcatheter Versus Surgical Treatment for Young and Low-Risk Patients

Abstract

Transcatheter aortic valve replacement is now indicated across all risk categories of patients with symptomatic severe aortic stenosis and has been proposed as first line option for the majority of patients >74 years old. However, median age of patients enrolled in the transcatheter aortic valve replacement low-risk trials is 74 years and transcatheter aortic valve replacement has never been systematically investigated in young low risk patients. Although the long-term data in surgical aortic valve replacement in young patients (age <75) are well known, such data remain lacking in transcatheter aortic valve replacement. In the absence of clear guideline recommendations in patients with challenging anatomies (eg, hostile calcium, bicuspid), it is important to know the potential advantages and disadvantages of each treatment and to consider how they might integrate with each other in the lifetime management of such patients. In this review, we discuss current outstanding issues on the management of severe aortic stenosis from a lifetime management perspective, particularly in terms of initial intervention and future reinterventions.

Redo-TAVR Feasibility After SAPIEN 3 Stratified by Implant Depth and Commissural Alignment: A CT Simulation Study

“…With the adoption of TAVR in younger, lower-risk patients, consideration of lifetime management of aortic stenosis is of increasing importance. 3 Recognizing that younger patients may require multiple aortic valve interventions over their lifetime, it is imperative for the Heart Team to consider the patient’s suitability for THV reintervention during procedural planning for their index procedure. Several patient-specific, THV-specific, and procedure-specific factors affect the viability of a redo-TAVR.…”

“…15 This underlines the importance of individualizing valve sizing and target implant depth decisions, especially in younger patients, where the lifetime management of aortic valve disease and reintervention would be important. 3,13 Commissural alignment of the index THV is important to facilitate leaflet modification techniques such as BASILICA (bioprosthetic or native aortic scallop intentional laceration) or the use of dedicated leaflet cutting/ removal devices. Splitting or removal of the interfering leaflet(s) can reduce the functional neoskirt height, mitigating risk of coronary obstruction or sinus sequestration.…”

“…1,2 As the adoption of TAVR continues to grow, particularly in younger patients at lower surgical risk, lifetime management and the need for re-interventions become increasingly relevant. 3 Management of failed transcatheter heart valves (THVs) poses a clinical challenge, with surgical TAVR explant or redo-TAVR being 2 treatment options. With multiple studies now indicating the technical challenges and high mortality associated with TAVR explant, redo-TAVR is being increasingly considered as the treatment of choice in patients with THV failure.…”

Ten-Year Experience with Transapical and Direct Transaortic Transcatheter Aortic Valve Replacement to Address Patients with Aortic Stenosis and Peripheral Vascular Disease

“…Aortic valve stenosis is the most common heart valve disease in adults and standard surgical replacement remains the treatment of choice [1][2][3]. However, elderly patients, patients at risk for surgery, patients undergoing reinterventions, and, more recently, also patients with an intermediate risk profile can be successfully treated with a transcatheter aortic valve replacement (TAVR) performed through a transfemoral access or alternative access routes [4][5][6][7][8][9].…”

Revisiting the ACURATE-Neo Valve: Slow Starter But a Hopeful Finisher?

“…Lifetime management of aortic valve disease is evolving given the rapid expansion of TAVR in younger, low surgical risk patients with longer life expectancies. 1 Therefore, decision making process extends beyond the anatomic factors and involves several outstanding issues, such as valve durability, coronary access, feasibility for redo-TAVR, and avoiding periprocedural complications such as paravalvular leak (PVL), permanent pacemaker and prosthesis-patient mismatch.…”