Transcatheter Treatment of Valvular Heart Disease

Abstract

ImportanceMore than 40 million people are living with either mitral or aortic valve disease worldwide, and more than 180 000 heart valve replacement surgeries are performed each year in the US. Transcatheter valve repair has emerged as an important therapeutic option for patients who are candidates for heart valve replacement.ObservationsAll transcatheter valve therapies involve a multidisciplinary team of interventional cardiologists, cardiothoracic surgeons, radiologists, echocardiographers, nurses, and social workers, termed the heart team, to determine the optimal approach for managing each patient. Transcatheter aortic valve implantation (TAVI) is an aortic valve replacement procedure that is performed percutaneously and is currently approved for patients with severe, symptomatic aortic stenosis in all surgical risk categories. The TAVI procedure can be performed using a balloon-expandable or self-expanding valve. In a low-risk cohort of patients (PARTNER [Placement of Aortic Transcatheter Valves] 3 trial), the rates of death from any cause, stroke, or rehospitalization were 8.5% for patients receiving TAVI and 15.1% for patients undergoing surgical aortic valve replacement. Decision-making regarding therapy choice should be based on individual anatomy (including the number of leaflets, annular size, and peripheral arterial anatomy), comorbidities (including concomitant coronary artery disease and aortopathies), and patient preference guide. A mitral transcatheter edge-to-edge repair device is approved by the US Food and Drug Administration for high-risk patients with degenerative and functional mitral regurgitation that has excellent safety and efficacy in these populations. In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial, the annualized rate of all hospitalizations for heart failure was 35.8% among patients who underwent transcatheter edge-to-edge repair and received medical therapy compared with 67.9% among patients in the medical therapy alone group. Transcatheter tricuspid valve repair and replacement trials are ongoing and show promise for the treatment of patients with tricuspid regurgitation, which previously had limited therapeutic options. Multimodality imaging, which includes transthoracic echocardiography, transesophageal echocardiography, computed tomography, and intracardiac echocardiography, is important for preprocedural planning, device selection, and optimal outcomes.Conclusions and RelevanceApproximately 78 000 TAVI procedures and 10 000 transcatheter mitral valve repairs take place yearly in the US to treat patients with severe, symptomatic aortic stenosis and mitral regurgitation, respectively. Transcatheter valve therapies have expanded therapeutic options for patients, including for those who previously had no viable surgical options.

Characteristics and outcomes following transcatheter aortic valve replacement in China: a report from China aortic valve transcatheter replacement registry (CARRY)

“…[ 21 ] The majority of TAVR procedures are performed through a transfemoral access (98.2%) in China, which is higher than that in other registries or national databases. [ 14 , 22 ] This could be because TAVR took off late in China; consequently, operators favor a more established and safer route of transfemoral access. This trend is mirrored in the Society of Thoracic Surgeons (STS)/TVT database, which showed that before 2013, transfemoral access was adopted in only 57.08%, and by 2019, the figure reached 95.26% ( P trends < 0.001).…”

Heart–Brain Relationship in Stroke

“…In a study of rivaroxaban compared to warfarin in patients with both AF and a bioprosthetic mitral valve, the NOAC was reported to be noninferior to warfarin in terms of the primary outcome at 12 months of either death, major cardiovascular events or major bleeding [ 55 ]. Transcatheter treatment of valvular heart disease is gaining increasing utilization in recognition of enhanced safety [ 56 ]. Transcatheter aortic valve implantation (TAVI) can be performed with either a balloon-expandable or self-expanding valve, and is performed percutaneously.…”

“…For lower risk patients, the rate of death from any cause, stroke or rehospitalization was 8.5% with TAVI and 15.1% for surgical aortic valve replacement according to one study [ 57 ]. For mitral regurgitation, there is now an FDA-approved mitral transcatheter edge-to-edge repair device for higher risk patients with severe symptomatic mitral regurgitation [ 56 ]. In the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients (COAPT) study [ 58 ], intervention resulted in annualized rate of hospital admissions of 35.8% compared to 67.9% for those who received medical therapy alone.…”

Epidemiological Trends in Patients Undergoing Mitral Valve Transcatheter Edge-to-Edge Repair over the Last Decade: Functional vs. Structural Mitral Regurgitation

“…Transcatheter edge-to-edge repair (TEER) of the mitral valve (MV) caused a revolution in MR treatment when the MitraClip system (Abbott) was approved in Europe in 2008 for both indications, i.e., SMR and FMR, whereas it was approved in 2013 in the United States and only for SMR [ 3 ]. The treatment was primarily intended for FMR patients with very high operative risk, but it was soon adopted as an efficient therapeutic option in SMR patients with unacceptable operative risk [ 4 , 5 ]. More than one decade later, a new system for MV TEER, the PASCAL device (Edwards), was approved in Europe, but still not in the US.…”

“…Over more than one decade, our knowledge about MV repair has significantly increased; however, most published studies have been focused on the outcomes of MR patients after this procedure [ 4 , 5 ]. The demographic and clinical characteristics of SMR and FMR patients who underwent this procedure have been significantly less investigated.…”