Increased utilization of bioprosthetic aortic valve technology:Trends, drivers, controversies and future directions

ABSTRACT

Introduction: Bioprosthetic valves (BPV) implanted surgically or by transcatheter valve implantation (TAVI) comprise an overwhelming majority of substitute aortic valves implanted worldwide.

Areas Covered: Prominent drivers of this trend are: 1) BPV patients have generally better outcomes than those with a mechanical valve, and remain largely free of anticoagulation and its consequences; 2) BPV durability has improved over the years; and 3) the expanding use of TAVI and valve-in-valve (VIV) procedures permitting interventional management of structural valve degeneration (SVD). Nevertheless, key controversies exist: 1) optimal anticoagulation regimens for surgical and TAVI BPVs; 2) the incidence, mechanisms and mitigation strategies for SVD; 3) the use of VIV for treatment of SVD, and 4) valve selection recommendations for difficult cohorts, (e.g. patients 50–70 years, patients <50, childbearing age women). This communication reviews trends in and drivers of BPV utilization, current controversies, and future directions affecting BPV use.

Expert Opinion: Long-term data are needed in several areas related to aortic BPV use, including anticoagulation/antiplatelet therapy, especially following TAVI. TAVI and especially VIV durability and optimal use warrant will benefit greatly from long-term data. Certain populations may benefit from such high-quality data on multi-year outcomes, particularly younger patients.

KEYWORDS:

• Anticoagulation
• aortic valve
• bioprosthetic valve
• structural valve degeneration calcification
• transcatheter valve implantation (TAVI)
• valve thrombosis
• valve-in-valve

Declaration of interest

F. Schoen is a paid consultant to BioCompatibility Innovations, CroiValve, WL Gore, LivaNova, Medtronic and a paid consultant and Scientific Advisory Board member of Xeltis. R. Bianco is a consultant and Scientific Advisory Board member of Xeltis. 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.

Article Highlights

• Bioprosthetic aortic valves have gained dominant use due to low thrombogenicity, transcatheter techniques, and advances in durability.

• No consensus exists on chronic anticoagulation regimens in bioprosthetic aortic valves, and recent data suggest a higher thrombotic risk than previously suspected, with uncertain consequences

• TAVI including valve-in-valve interventions has flourished but long-term outcomes are still unclear

• Considerations for valve selection in particular patient populations are outlined

• Critical areas for further study are summarized

Reviewer disclosures

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

Additional information

Funding

This paper was not funded.