TAVI and the future of aortic valve replacement

Abstract

Aortic valve stenosis (AS) is the most common valvular pathology and has traditionally been managed using surgical aortic valve replacement (SAVR). A large proportion of affected patient demographics, however, are unfit to undergo major surgery given underlying comorbidities. Since its introduction in 2002, transcatheter aortic valve implantation (TAVI) has gained popularity and transformed the care available to different-risk group patients with severe symptomatic AS. Specific qualifying criteria and refinement of TAVI techniques are fundamental in determining successful outcomes for intervention. Given the successful applicability in high-risk patients, TAVI has been further developed and trialed in intermediate and low-risk patients. Within intermediate-risk patient groups, TAVI was shown to be noninferior to SAVR evaluating 30-d mortality and secondary endpoints such as the risk of bleeding, development of acute kidney injury, and length of admission. The feasibility of expanding TAVI procedures into low-risk patients is still a controversial topic in the literature. A number of trials have recently been published which demonstrate TAVI as noninferior and even superior over SAVR for primary study endpoints. K E Y W O R D S aortic valve, surgery, TAVI, valve replacement 1 | INTRODUCTION Aortic valve stenosis (AS) is the most common valvular pathology, with between 2% and 4% of patients over the age of 75 years bring affected. 1 For decades, surgical aortic valve replacement (SAVR) has been considered the class I recommendation in the management of AS. 2 However, given that advanced age, frailty, and significant comorbidities are increasingly prevalent in affected patients; more than one-third of high-risk and severe symptomatic AS patients were not considered physiologically fit enough for major surgical intervention. 2,3 This merited the development of TAVI, an intervention suitable for high-risk patients and those deemed unfit for surgery. With a shift in clinical paradigm toward minimally invasive procedures, the development of TAVI has revolutionized clinical outcomes in AS, particularly in those once considered inoperable. 4 The decision to use TAVI vs SAVR for aortic valve replacement (AVR) is determined by clinical, anatomical, and technical considerations. Since its introduction in 2002, 5 TAVI has increasingly replaced SAVR, the once considered gold standard treatment, in aortic valve diseases. 6-10 More recently, trials such as the Placement of Aortic Trans-Catheter Valve II (PARTNER II) and Surgical Replacement and Transcatheter Aortic Valve Implantation (SURTAVI) 11,12 have further established the use of TAVI in intermediate-risk patients as well. Given this validation of TAVI within high-and intermediate-risk patients, a need has now developed to evaluate the clinical efficacy of TAVI within low-risk surgical candidates. 13Selective candidate criteria, as well as advances in operative techniques within TAVI, are mainstay contributors to successful outcomes. Fundamentally, there exist both retrogr...

Pregnancy and cardiac interventions: What are the optimal management options?

“…Aortic regurgitation may be well tolerated possibly due to a decrease in systemic vascular resistance and the physiological increase in heart rate during pregnancy. [18][19][20] This may eventually lead to reduced severity of regurgitation. As pregnancy is a volume overload state, the severity of regurgitation may increase leading to symptoms of pulmonary congestion.…”

“…European Society of Cardiology (ESC) and American College of Cardiology (ACC) both recommend initial medical treatment of symptomatic patients. 18,19,21 This may include the use of diuretics, vasodilators, and beta-blockers for congestive symptoms of heart failure.…”

“…However, only a few successful reports have been published supporting the use of TAVI. 19,21,25 A case report from 2016, published that TAVI has been associated with a lower risk of complications for both the mother and fetus. 25 Table 1 is a summary of key management approaches for aortic valve diseases during pregnancy.…”

“…19 According to the Registry on Cardiac Disease and Pregnancy (ROPAC), it has been reported that pregnant patients with severe mitral stenosis, with a valve area of less than 1.0 cm, had up to 67% risk of maternal complications. 19,20 ESC and ACC have reported the importance of restricting physical activity and dietary measures such as reducing sodium intake to reduce heart rate and optimize left atrial pressure, therefore improving symptoms. 18,21 They have reported the use of medical treatment in symptomatic patients with mild to moderate mitral stenosis.…”

“…If patients remain refractory to this, percutaneous balloon mitral valvotomy (PBMV) is the next universally recommended procedure. [18][19][20][21] ACC has looked into various studies on the use of PBMV during pregnancy and their outcomes. 18 This has been seen to improve the haemodynamic status and symptoms of the patient.…”