Long-term outlook for transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) revolutionized the treatment of severe symptomatic aortic stenosis (AS). TAVR is increasingly offered for lower-risk patients. The role and place of TAVR in the future treatment of AS is not clear yet. In this review, we discuss the long-term outlook for TAVR, its challenges and its relationship to conventional surgical aortic valve replacement.     

Bioprosthetic aortic valve leaflet disruption with high energy electrocautery to prevent coronary artery obstruction during valve‐in‐valve transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is well‐established for the treatment of bioprosthetic aortic valve stenosis (AS) in high surgical risk patients. Coronary artery obstruction from displacement of the bioprosthetic valve leaflets during valve‐in‐valve (VIV) TAVR is a rare, but potentially fatal, complication. Recently, the bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure was developed as a method for disrupting bioprosthetic leaflets in patients undergoing VIV TAVR at high risk for coronary obstruction. This case describes a successful VIV TAVR utilizing a simplified concept of the BASILICA technique in a patient where the full procedure could not be completed.     

Combined surgical and catheter‐based treatment of extensive thoracic aortic aneurysm and aortic valve stenosis

An extensive thoracic aortic aneurysm (TAA) is a potentially life‐threatening condition and remains a technical challenge to surgeons. Over the past decade, repair of aortic arch aneurysms has been accomplished using both hybrid (open and endovascular) and totally endovascular techniques. Thoracic endovascular aneurysm repair (TEVAR) has changed and extended management options in thoracic aorta disease, including in those patients deemed unfit or unsuitable for open surgery. Accordingly, transcatheter aortic valve replacement (TAVR) is increasingly used to treat patients with symptomatic severe aortic valve stenosis (AS) who are considered at high risk for surgical aortic valve replacement. In this report, we describe the combined surgical and catheter‐based treatment of an extensive TAA and AS. To our knowledge, this is the first report of hybrid TAA repair combined with TAVR. © 2014 Wiley Periodicals, Inc.     

Transcatheter aortic valve replacement: The year in review 2016

Transcatheter aortic valve replacement (TAVR) continued to make major strides in 2016, simultaneously expanding its application to lower risk patients as well as more technically challenging subsets of patients with aortic stenosis (AS). The two major accomplishments this year were the establishment of TAVR as the preferred treatment strategy over surgical aortic valve replacement (SAVR) in intermediate risk patients, and initial signals that TAVR and SAVR may be clinically equivalent in low‐risk populations. Meanwhile, there is continued expansion of TAVR to challenging clinical subsets (bicuspid aortic valve [BAV], patients with concomitant advanced coronary artery disease [CAD], and failed surgical bioprostheses), and encouraging initial experiences with newer transcatheter heart valve systems. This paper summarizes the major research studies published on TAVR in 2016.

     

Mixed aortic valve disease treated with transcatheter aortic valve replacement in a high risk patient presenting with acute decompensated heart failure

Mixed aortic valve disease refers to the combination of aortic regurgitation (AR) and aortic stenosis (AS). Commonly etiologies include a bicuspid aortic valve, rheumatic heart disease, and endocarditis superimposed upon a stenotic aortic valve. Treatment depends upon the severity of disease, the presence of symptoms and the size and function of the left ventricle. We present a case of a young patient that presented with new onset acute decompensated heart failure with mixed aortic valve disease that was successful treated with transcatheter aortic valve replacement (TAVR). Invasive hemodynamics at baseline and following TAVR provide an insight into the characteristic features of mixed aortic valve disease. TAVR represents a new treatment option for critically ill patients deemed high risk or nonoperable for surgical aortic valve replacement.     

Successful transfemoral aortic valve replacement in a bicuspid aortic stenotic valve: Requirements for a safe implant

Although transcatheter aortic valve replacement (TAVR) has been accepted as an attractive alternative for high‐risk patients with severe symptomatic aortic stenosis (AS), patients with congenital bicuspid AS has been typically disqualified for this indication due to an implied risk of device dislocation, distortion, or device malfunctioning. Nonetheless, bicuspid AS is not uncommon and frequently missed by transthoracic echocardiography. We reported an interesting case of a high‐risk patient with severe symptomatic bicuspid AS who underwent successful TAVR and discussed the anatomic requirements for a safe implant in patients with bicuspid AS considered candidates for TAVR. © 2013 Wiley Periodicals, Inc.     

The first case of “locked‐in leaflet” after transcatheter aortic valve replacement in a patient with bicuspid aortic stenosis

This case report is about an 85‐year‐old woman with bicuspid aortic stenosis (AS). Although preoperative multimodality imaging showed challenging anatomical aspects, transcatheter aortic valve replacement (TAVR) was selected to be performed as a less invasive alternative treatment approach, owing to her comorbidity. Postoperative transesophageal echocardiography and multidetector‐row computed tomography revealed the presence of “locked‐in leaflet” caused by stent distortion due to pinching by calcified native leaflets, with nodular calcification preventing the full expansion of the valve, which resulted in moderate perivalvular leakage. This is the first reported case of bicuspid AS treated with TAVR that eventually resulted in “locked‐in leaflet.”     

Transcatheter aortic valve replacement: A novel abdominal transaortic approach

Transcatheter aortic valve replacement (TAVR) via the transfemoral (TF), transapical (TA), or even the transaortic (TAO) approach in high‐risk or inoperable patients is quickly becoming a safe and effective modality for the treatment of symptomatic severe aortic stenosis (AS). However, in this selected group of patients, those with anatomical or physiologic constraints preventing TF, TA, and conventional TAO TAVR, alternative sites of access must be explored. Here, we report a successful TAVR in an inoperable patient with severe AS using a distal abdominal TAO approach via a synthetic graft‐conduit. © 2013 Wiley Periodicals, Inc.     

Outcomes of Surgical Aortic Valve Replacement: The Benchmark for Percutaneous Therapies

Historically, many patients with severe senile calcific aortic valve stenosis (AS) were not offered surgery, largely due to the perception that the risks of operation were prohibitive. Such patients have subsequently been formally designated as ‘high risk’ or ‘inoperable’ with respect to their suitability for surgical aortic valve replacement (SAVR) in the evolving lexicon of heart valve disease. The recent availability of transcatheter aortic valve replacement (TAVR) represents an alternative treatment option, and permits the opportunity to re-examine algorithms for assessing operative risk. As the experience with TAVR grows, expanded use in new patient populations can be anticipated. While TAVR in high risk AS patients has demonstrated benefits, the emerging indication in intermediate AS is less clear and conclusions will necessarily await the availability of results from ongoing clinical trials. This article will discuss current outcomes for SAVR among high- and intermediate-risk patients with AS as a barometer in assessing the results of nascent percutaneous therapies.     

Simultaneous thoracic aortic endovascular graft and transfemoral transcatheter aortic valve replacement in a patient with a descending aortic thrombus

Severe descending thoracic and abdominal aortic pathology can deter consideration of transfemoral (TF) access for transcatheter aortic valve replacement (TAVR) in adults with severe symptomatic aortic stenosis (AS) and may lead to utilization of alternative access sites. We report a case of an 88-year-old frail woman with severe symptomatic AS referred for TAVR with demonstration of a large thrombus in the descending thoracic aorta immediately distal to the left subclavian artery. Given concerns of thrombus embolization with femoral advancement of the transcatheter valve, coverage with a thoracic aortic endograft was planned immediately prior to the TAVR.     

Changes in myocardial deformation after transcatheter and surgical aortic valve replacement

Speckle tracking echocardiography (STE) has emerged as a novel angle‐independent modality in assessing myocardial velocity, deformation, and strain. Its role in assessing change before and after aortic valve replacement in patients with aortic stenosis (AS) has recently generated interest. This review summarizes the practical utility and clinical implications of myocardial deformation by STE after surgical or transcatheter aortic valve replacement (TAVR). Overall, atrial strain and ventricular strain as measured by STE improve after surgical and transcatheter aortic intervention in short‐ and long‐term follow‐up with evidence of a more pronounced acute improvement in patients who undergo TAVR. STE assessment of strain, particularly global longitudinal strain, can detect subtle changes in myocardial systolic function prior to conventional variables such as left ventricular ejection fraction and is clinically useful in predicting mortality and symptom development in patients with AS. This underscores the emerging role of STE in monitoring post‐procedural improvements in cardiac function as well as the potential value in guiding optimal timing of AS intervention.     

Postextrasystolic Potentiation in Low‐Gradient,Severe Aortic Stenosis: A Poor Man's Stress Echo?

An elderly man with dyspnea and syncope was found to have severe aortic stenosis (AS) by the continuity equation, despite a transaortic gradient that was only moderately elevated, in the setting of severe left ventricular dysfunction. The transaortic gradient increased during postextrasystolic beats, suggesting that his that his AS was truly severe; this was confirmed by dobutamine echocardiography. He underwent transcatheter aortic‐valve replacement (TAVR), with subsequent improvement in left ventricular systolic function. The diagnostic and prognostic significance of postextrasystolic potentiation, with associated increase in aortic stenosis gradient, deserves renewed attention in the TAVR era.     

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis

Aortic stenosis (AS) is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement (SAVR) has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged. Transcatheter aortic valve replacement (TAVR) is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety (e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing). The impact of comorbidities (pulmonary hypertension, arterial hypertension and obesity paradox), the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category (extremely high, high, intermediate and low risk) are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.     

Procedural and clinical outcomes of the valve‐in‐valve technique for severe aortic insufficiency after balloon‐expandable transcatheter aortic valve replacement

Objective : To describe the clinical and procedural outcomes of patients treated with the valve‐in‐valve technique for severe aortic insufficiency (AI) after balloon‐expandable transcatheter aortic valve replacement (TAVR). Background : Severe AI immediately after valve implantation is a notable complication of TAVR. It can be treated with a valve‐in‐valve technique which involves deploying a second valve within the first one to crush the leaflets of the first implant leaving a new functional valve. Methods : We analyzed data on 142 consecutive patients at our institution undergoing TAVR with the Sapien valve between November of 2007 and April of 2011. Etiologies of acute AI, procedural and intermediate term clinical outcomes were reported for those in whom a valve‐in‐valve procedure was necessary. Post‐hoc analysis of these cases with C‐THV imaging (Paieon Medical Ltd.) was performed to elucidate the mechanism for successful AI treatment. Results : A total of 5 of 142 (3.5%) patients were treated with the valve‐in‐valve technique. Etiologies of the aortic valve insufficiency included bioprosthesis malposition (n = 3), valve dysfunction (n = 1), and valve undersizing (n = 1). With placement of the second valve, the first valve dimensions increased to approach the nominal valve size while the second valve size remained less than nominal. Conclusions : The valve‐in‐valve technique is an appropriate bailout measure for patients with acute valvular AI after balloon‐expandable TAVR. © 2012 Wiley Periodicals Inc.     

The use of MitraClip to prevent posttranscatheter aortic valve replacement left ventricular “suicide”

Patients with concomitant severe aortic stenosis (AS) and left ventricular outflow tract (LVOT) obstruction undergoing transcatheter aortic valve replacement (TAVR) are at risk for hemodynamic collapse due to a sudden decrease in afterload causing worsening LVOT obstruction. We present a case of an 88-year-old female with symptomatic, severe AS, and LVOT obstruction with systolic anterior motion (SAM) of the mitral leaflet in whom alcohol septal ablation was contraindicated secondary to a chronic total occlusion of the right coronary artery that filled retrograde via septal collaterals. MitraClip at the time of TAVR was successfully performed to treat SAM with subsequent stabilization of LVOT gradients despite treatment of the patient's AS. This novel approach may represent a feasible option to prevent hemodynamic complications after TAVR in patients with significant LVOT obstruction secondary to SAM and AS.     

Is it really “paradoxical” or just the ventricle?

• Patients with paradoxical low flow low gradient (PLFLG) aortic stenosis (AS) have favorable mid‐term outcomes after transcatheter aortic valve replacement (TAVR). These outcomes were comparable to those patients with high gradient AS (HGAS).
• Clinicians should avoid delaying referral of patients with PLFLG AS for valve replacement for either surgical aortic valve replacement (SAVR) or TAVR.
• Further studies are need to understand the increased early mortality after TAVR in PLFLG AS compared to HGAS, and to determine whether improvements of TAVR procedural techniques can result in better outcomes.

     

Iatrogenic communications between aortic root and right ventricle/left atrium after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative, less invasive treatment option for patients with severe symptomatic aortic stenosis, who are high‐risk for conventional surgical aortic valve replacement, due to co‐morbidities. In addition to a 30‐day 10% mortality risk there is a recognized range of complications, which commonly relate to vascular access trauma, paravalvular aortic regurgitation, and cerebrovascular events. In the following case reports, we discuss two previously unreported complications of TAVR: (i) an iatrogenic communication between the aortic root and the right ventricle and (ii) an iatrogenic communication between the aortic root and the left atrium. Informed written consent was obtained from both paztients. © 2013 Wiley Periodicals, Inc.     

Transcatheter Closure of Atrial Septal Defect with Attenuated Anterior Rim after Transcatheter Aortic Valve Implantation: Can It Be Carried out as a Single Procedure?

Transcatheter aortic valve replacement (TAVR) has emerged as a highly effective minimally invasive treatment for symptomatically critical aortic stenosis (AS) in patients at high or prohibitive surgical risk. We report a case of staged transcatheter management of critical AS combined with an atrial septal defect (ASD) with attenuated anterior superior rim. The clinical result of this case suggests that both procedures can be safely performed simultaneously. Therefore, combined transcatheter treatment may appear as a possible strategy in patients with concomitant cardiac conditions.     

Perceval sutureless valve migration treated by valve‐in‐valve with a CoreValve Evolut Pro

In the last years, the use of sutureless devices in frail patients with severe aortic stenosis has increased thanks to their “easier and faster” technique of implantation in comparison to conventional surgery. Results from metanalysis show comparable outcomes in comparison to transcatheter aortic valve replacement (TAVR) in terms of mortality, stroke incidence, and rate of pace‐maker implantation. The incidence of para‐valvular leak (PVL) is even lower for sutureless devices than for TAVR. The few cases described are generally due to incomplete decalcification or incorrect valve sizing and consequent stent distortion. To our knowledge this is the first case describing PVL with massive aortic regurgitation due to early partial embolization of a Perceval valve and its successfully treatment with valve‐in‐valve by using a self‐expanding TAVR device.     

Emergent use of retrograde left ventricular support in patients after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is currently a therapeutic alternative to open aortic valve replacement for high‐risk patients with severe symptomatic aortic valve stenosis. The procedure is associated with some life‐threatening complications including circulatory collapse which may require temporary hemodynamic support. We describe our experience with the use of the Impella 2.5 system to provide emergent left ventricular support in cases of hemodynamic collapse after TAVR with the Edwards SAPIEN prosthesis.© 2012 Wiley Periodicals, Inc.