Developments in transcatheter aortic bioprosthesis durability

ABSTRACT

Introduction: Valve durability represents a main concern, as the target population for transcatheter aortic valve implantation (TAVI) evolves to include lower risk and younger patients who are likely to survive for a number of years after the procedure.

Areas covered: The purpose of this review article is to provide an overview of potential mechanisms and rates of structural valve deterioration (SVD) of transcatheter bioprostheses.

Expert opinion: Recently the standardized definitions of SVD proposed by European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) have permitted for the first time, an objective evaluation of existing and novel TAVI prostheses, and to compare their longevity versus surgical bioprostheses. Although the results of midterm durability of the transcatheter bioprostheses are encouraging, our knowledge concerning the clinical outcomes of TAVI beyond 5 years is still limited. Evidence of longer-term durability is mandatory before replacing surgery with TAVI, particularly in younger and lower-risk patients.

KEYWORDS:

• Surgical aortic valve replacement
• TAVI
• Durability
• Structural valve deterioration
• Bioprosthetic valve failure

Article highlights

• SVD is a progressive morphological process, with gradual deterioration in hemodynamic bioprosthetic valve functioning over time.

• In both SAVR and TAVI reports assessing long-term outcomes, the durability of the implanted bioprostheses has been defined in many dissimilar ways.

• Recently, the standardization of SVD definition by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) has permitted to obtain uniformity with comparable endpoint among data reporting of studies assessing long-term surgical or transcatheter valves durability.

• In the surgical field, several studies confirmed excellent long-term results, with reported bioprosthesis durability >85% at 10 years. However, most studies have used reoperation rate instead of valve performance characteristics to define valve durability leading to an underestimation of real incidence of SVD.

• In the TAVI field, assessments of preserved valve function have been extensively shown up to 5 years in randomized trial cohorts and multicentre registries. However, knowledge concerning the clinical outcomes of TAVI beyond 5 years is still scarce by the poor survival of our population.

• With the expansion of TAVI indications to lower risk and younger patients data on long-term TAVI durability are paramount.

• The ESC European Observational Registries Programme (EORP) has recently initiated a European multicenter registry of TAVI patients treated >5 years ago in order to evaluate the incidence, timing, and presentation of long-term bioprosthetic valve dysfunction in the real world.

Declaration of interest

A S Petronio is a consultant and research funding for Medtronic, Boston Scientific, Abbott, and GADA. 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.