TAVI and the future of aortic valve replacement

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.     

Mitral valve‐in‐valve replacement supported by a transapically snared guidewire via septostomy

We describe a 72‐year‐old woman, a known case of rheumatic heart disease with a history of mitral and aortic valve replacement 8 years previously, who underwent mitral valve‐in‐valve replacement supported by a transapically snared guidewire through septostomy.     

Transcatheter aortic valve implantation versus surgical aortic valve replacement during the COVID‐19 pandemic—Current practice and concerns

COVID‐19 has had a dramatic impact on the provision of healthcare. COVID‐19 can manifest with cardiac and thrombotic presentations. Additionally, patients with cardiovascular comorbidities are at an increased risk of adverse outcomes related to COVID‐19 infection. This in turn has led to a significant reduction in the provision of cardiac surgery with alternative management options utilized to address patients with significant disease. In terms of aortic valve disease, transcatheter aortic valve implantation (TAVI) provides advantages over surgical aortic valve replacement in with a lower burden on healthcare resources. COVID‐19 also resulted in changes in management strategies and as such TAVI is now being considered in younger‐ and low‐risk patients. However, long term data with regard to TAVI is still unknown, and the use in patient groups that have been excluded in the large pivotal studies that established TAVI as an alternative to surgery has raised specific concerns in the use of TAVI as the preferred treatment choice. With the long term ramification unknown, it is essential that decisions are made with caution.     

Trans‐carotid access for TAVR allows safe and rapid exchange for bailout valve‐in‐valve procedures

Trans‐carotid access for trans‐catheter aortic valve replacement is a valid alternative in patients with aortic valve dysfunction, severe peripheral vascular disease, and high‐risk for surgery. However, in the event of the need for a bailout valve‐in‐valve procedure, the safety of this access site is uncertain. We report a patient with aortic regurgitation, previous coronary surgery, peripheral vascular disease, and impaired ventricular function who underwent a CoreValve Evolut‐R (Medtronic Inc, Minneapolis, MN) implantation through the left carotid artery followed by a successful valve‐in‐valve procedure with a 26‐mm Edwards Sapien3 valve (Edwards Lifesciences, Irvine, CA) through the same carotid access site.     

Transcatheter aortic valve replacement in patients with severe mitral or tricuspid regurgitation at extreme risk for surgery

Objectives

Patients with symptomatic severe aortic stenosis and severe mitral regurgitation or severe tricuspid regurgitation were excluded from the major transcatheter aortic valve replacement trials. We studied these 2 subgroups in patients at extreme risk for surgery in the prospective, nonrandomized, single-arm CoreValve US Expanded Use Study.

Implementation of transcatheter aortic valve replacement in California: Influence on aortic valve surgery

Objective

Transcatheter aortic valve replacement (TAVR) procedures were introduced in 2011. Initially, procedures were limited to patients who were not surgical candidates, but subsequently high-risk surgical candidates were considered for TAVR. The influence on aortic valve surgery in California is unknown.

Transfemoral aortic valve replacement with the SAPIEN XT valve: step-by-step

Transcatheter aortic valve replacement (TAVR) has become an attractive alternative for patients with severe aortic stenosis at high surgical risk. We describe a step-by-step approach to performing TAVR with the SAPIEN XT valve.     

Percutaneous valve‐in‐valve procedure and simultaneous paravalvular leak closure

Concern for early degeneration limits the use of bioprosthetic heart valves. A 77‐year‐old man who underwent surgical aortic valve replacement at age 70 for severe aortic stenosis (AoS) presented with premature bioprosthesis degeneration and AoS recurrence. Transthoracic echocardiography demonstrated severe AoS and aortic regurgitation, a 30% ejection fraction, and pulmonary hypertension. Transesophageal echocardiography revealed that the aortic regurgitation was due to a 5‐mm paravalvular leak (PVL). A high EuroScoreII excluded surgical treatment. Simultaneous transcatheter aortic valve replacement and PVL closure with an Occlutech PLD Square 5 Twist PVL closure device were performed with good results and improved clinical status.     

Evolving trends in aortic valve replacement: A statewide experience

Background

Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for the treatment of aortic stenosis in patients at intermediate, high, and extreme risk for mortality from SAVR. We examined recent trends in aortic valve replacement (AVR) in Michigan.

Methods

The Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS‐QC) database was used to determine the number of SAVR and TAVR cases performed from January 2012 through June 2017. Patients were divided into low, intermediate, high, and extreme risk groups based on STS predicted risk of mortality (PROM). TAVR patients in the MSTCVS‐QC database were also matched with those in the Transcatheter Valve Therapy Registry to determine their Heart Team‐designated risk category.

Results

During the study period 9517 SAVR and 4470 TAVR cases were performed. Total annual AVR volume increased by 40.0% (from 2086 to 2920), with a 13.3% decrease in number of SAVR cases (from 1892 to 1640) and a 560% increase in number of TAVR cases (from 194 to 1280). Greater than 90% of SAVR patients had PROM ≤8%. While >70% of TAVR patients had PROM ≤ 8%, they were mostly designated as high or extreme risk by a Heart Team.

Conclusions

During the study period, SAVR volume gradually declined and TAVR volume dramatically increased. This was mostly due to a new group of patients with lower STS PROM who were designated as higher risk by a Heart Team due to characteristics not completely captured by the STS PROM score.