Predicting and improving outcomes of transcatheter aortic valve replacement in older adults and the elderly

ABSTRACT

Introduction

Indications for transcatheter aortic valve replacement (TAVR) are progressively extending to younger and lower risk patients. In this scenario, minimizing periprocedural complications and optimizing procedural result are both crucial to achieve an excellent long-term outcome.

Areas covered

In this review, we summarize the main strategies that can be adopted before, during, and after TAVR to predict and prevent complications, to optimize procedural results and ultimately improve outcomes, with an emphasis on more recent evidence, new devices, and new techniques.

Expert opinion

In the next future TAVR will probably represent the first treatment option for patients affected by aortic valve stenosis who are candidates to receive a biological valve. Continuous refinement of TAVR devices has been key to allow safer and most effective procedures and further progress is expected. Development of new techniques and devices, such as ultrasound-guided puncture and intravascular lithotripsy, will expand safety and eligibility to transfemoral procedures. Effective preemptive measures for coronary occlusion have been developed. Open issues include cerebral protection, re-access to coronary arteries, post-procedural management, and therapy.

KEYWORDS:

• Transcatheter aortic valve implantation
• complications
• outcomes
• procedural planning

Article highlights

• Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for elderly patients with severe aortic stenosis and indications are progressively extending to lower risk and younger patients

• Outcomes of TAVR have constantly improved over the years, thanks to remarkable devices’ ameliorations and growing experience of interventional cardiologists

• New techniques and new devices are increasing the feasibility and the safety of transfemoral approach

• Meticulous procedural planning and the ability to prevent and timely treat procedural complications are key to optimize the results of TAVR

• Promising data are available for treatment of bicuspid valves, coronary protection, minimalist approach and early-discharge protocols, but further research is needed.

• In order to further expand indications for TAVR, a few pending issues must be clarified, including durability, need for cerebral protection, anti-thrombotic therapy, future access to the coronary ostia.

Reviewer disclosures

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

Declaration of interest

F Saia reports personal fees from Abbott Vascular, Eli Lilly, AstraZeneca, Boston Scientific, Medtronic Inc, The Medicines Company, Biotronik and St Jude, outside this work. T Palmerini has received speaker fee from Abbott Vascular and research grant from Eli Lilly. 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.

Additional information

Funding

This paper was not funded.