Early detection of transcatheter heart valve dysfunction

ABSTRACT

Introduction: Transcatheter aortic valve implantation therapy is spreading rapidly, representing the standard of care in inoperable and high-risk patients, and a valid alternative in intermediate- and low-risk patients with severe symptomatic aortic stenosis. In this subset, the development and validation of noninvasive, quantitative, in vivo imaging modality, to monitor possible valve dysfunction is mandatory, in order to plan timely therapeutic interventions before the onset of symptoms.

Areas covered: The implantation of transcatheter heart valves (THV) is increasing rapidly. As a consequence, THV dysfunction will become a major cause of cardiovascular morbidity after TAVI. Emergency repeat aortic valve replacement surgery is associated with a high rate of mortality compared with elective repeat surgery. In this context, early detection of THV dysfunction is therefore highly desirable. The review aims to examine the different diagnostic method to early detect THV dysfunction.

Expert opinion: Most promising innovations in the diagnosis of early detection of THV dysfunction are evaluated, and the future outlook is explored. Waiting for upcoming evidence about the utility of CT, CMR, and PET on early detection of THV dysfunction, tailoring echocardiogram follow-up based on patients’ characteristics is the desirable approach.

KEYWORDS:

• Transcatheter aortic valve implantation
• Transcatheter heart valve
• Prosthesis failure
• Echocardiography
• Early diagnosis
• Positron Emission Tomography
• Multidetector Computed Tomography
• Leaflet Thrombosis

Article highlights

• With the rapid increase of transcatheter aortic valve implantation, transcatheter heart valve degeneration will become a major cause of cardiovascular morbidity over the coming decades.

• The pathophysiology of transcatheter heart valve degeneration is not completely understood yet, however calcium deposition and valve inflammation are keys process in the degeneration of bioprosthetic aortic valves.

• The echocardiographic is the standard imaging modality for evaluating transcatheter heart valve function.

• If on the one hand multidetector computed tomography allows precise morphological visualization of the transcatheter heart valve and it is highly sensitive in detecting of valve thrombosis at early stages of the process, on the other cannot determine aortic valve gradients and is therefore of reduced utility for the diagnosis of SVD.

• The CMR could have a significant role after TAVI in the assessment of intravalvular and/or paravalvular regurgitation severity, providing a superior prognostic value than echocardiography.

• ¹⁸F NaF PET can identify a wide range of degenerative processes including micro- and macrocalcification, fibrosis, thrombosis, and leaflet degeneration with disrupted collagen architecture and so may detect and quantify the early stages of valvular dysfunction.

Declaration of interest

M Barbanti is a consultant for Edwards Lifesciences and advisory board member for Biotronik. The authors have no other 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 apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.