Transcatheter aortic valve implantation: technique, complications and perspectives

Abstract

Transcatheter aortic valve implantation (TAVI) has become the preferred treatment option for patients with symptomatic severe aortic stenosis who are inoperable or at high risk for surgical aortic valve replacement. TAVI has shown a clear mortality benefit compared to conservative treatment in inoperable patients, and is at least non-inferior to surgical aortic valve replacement in high-risk operable patients. Through improvements in the field of imaging, refinement in valve technologies, increasing operator and team experience and continuous valuable research, TAVI has developed rapidly in the past years and is expected to further boost in the near future. In this review, we discuss the technical and procedural aspects of TAVI, the acute and late outcomes, and highlight the current expectations and potential future development of this rapidly evolving technology.

Keywords::

• aortic stenosis
• complication
• outcome
• paravalvular leak
• perspective
• TAVI
• technique
• upcoming valve

Financial & competing interests disclosure

M Abdel-Wahab received Institutional research grant from Medtronic, lecture fees from Boston Scientifc and Edwards Lifesciences. G Richardt received Institutional research grant from Medtronic, lecture fees from Boston Scientifc. The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The results of several large multicenter registries and randomized trials have provided data confirming transcatheter aortic valve implantation (TAVI) nowadays as the standard of care for inoperable patients with severe symptomatic aortic stenosis, and as an attractive alternative to surgical aortic valve replacement in patients who are considered high-risk for conventional surgery.

• A precise pre-procedural assessment and risk-stratification with a combination of imaging modalities is the key to a successful planning of TAVI.

• The choice of the appropriate vascular approach limits vascular and bleeding complications and impacts outcome after TAVI.

• Intra-procedural assessment of paravalvular aortic regurgitation (PAR) is of utmost importance as numerous registry data and randomized trials have shown that more-than-mild PAR is an independent predictor of mortality after TAVI. Every effort should be made to limit (during TAVI planning by proper valve choice) or manage this complication (balloon post-dilatation, valve in valve) when it occurs.

• Findings from the eight largest multicenter registries of TAVI published in the past few years in addition to the PARTNER, the recently published CoreValve US High Risk and the CHOICE randomized trials have all shown consistent and improving outcome after TAVI, but the long-term clinical outcome and hemodynamic valve performance data are awaited in the upcoming future.

• TAVI is a complex, technically demanding procedure performed in a high-risk, fragile patient cohort, with the potential for unexpected serious complications to occur in every step. The operator awareness and experience for such rapidly occurring complications, which must be dealt with promptly, is a necessity for a safe and successful procedure.

• Refinement of the technology with the upcoming valves, improvement of the procedural outcome and the awaited supporting body of evidence in the near future will lead to extending TAVI to the low-risk population with severe symptomatic aortic stenosis.

• Further randomized trials are needed to fill in the gaps of the still unanswered questions about this transforming technology.

Notes