Transcatheter aortic valve implantation 20 years later: early discharge after transfemoral minimalist procedures as a proof of effectiveness

Abstract

Aortic stenosis (AS) is the most frequent valvular heart disease in Western countries, as a consequence of the ageing population and of the growing prevalence of cardiovascular risk factors: 1 the incidence of AS in the elderly is estimated to be between 2 and 9% and the severity of AS increases with age, with one in eight people older than 75 years showing moderate to severe AS. 2 Historical data suggest poor survival in patients with symptomatic severe AS; after the onset of angina or syncope in patients with severe high-gradient AS, the average survival has been reported to be <2-3 years, while life expectation is 12-18 months in patients with AS and heart failure. 3,4 No medical treatment can change the natural history of AS and early valve intervention is recommended in all patients with symptomatic severe AS unless concomitant conditions exist that preclude at least 1-year survival. 5 In symptomatic patients, intervention is recommended for severe, high-gradient AS (mean gradient !40 mmHg, peak velocity !4.0 m/s and valve area 1.0 cm 2 or 0.6 cm 2 /m 2 ) or for severe low-flow (SVi 35 ml/m 2 ) low-gradient (<40 mmHg) AS with left ventricular dysfunction and evidence of contractile reserve. 5 In asymptomatic patients, intervention is recommended for severe AS and systolic left ventricular dysfunction of no other cause or when symptoms can be demonstrated on exercise testing. 5 In addition, development of symptoms in asymptomatic patients with severe AS can be predicted by older age, burden of risk factors for atherosclerosis, extent of valve calcification, peak jet velocity, comprehensive echocardiographic evaluation, and abnormal biomarker levels such as natriuretic peptides or cardiac troponins. 5