Transcatheter aortic valve replacement: potential use in lower-risk aortic stenosis

ABSTRACT

Introduction

The widespread use of transcatheter aortic valve implantation (TAVI) is expanding to low-risk patients. Nevertheless, a low clinical risk does not always correspond to a low procedural risk for the percutaneous approach.

Areas covered

The initial trials on TAVI in low-risk populations had encouraging results, showing non-inferiority in comparison to surgical aortic valve replacement (SAVR). However, the low-risk definition is based on risk score calculators developed for the surgical setting and not including other specific features that are more relevant to TAVI and can affect procedural outcomes. For example, the presence of bicuspid aortic valves, high calcific burden, low coronary height or conduction disturbances is all potentially associated with suboptimal results or even procedural complications. In addition, the lack of longer follow-up prevents us to draw conclusions about long-term outcomes, including data about valve durability and coronary re-access.

Expert opinion

Although current evidence suggest similar results for TAVI and SAVR in low-risk populations, there are some technical and procedural limitations that still need to be addressed in order to close the gap between TAVI and surgery. Optimal, lasting results with a low rate of procedural complications are highly expected in low-risk, otherwise healthy subjects, with potential for longevity.

KEYWORDS:

• Aortic stenosis
• low-risk population
• risk prediction
• SAVR
• TAVI

Article highlights

• SAVR is the gold standard treatment for low-risk patients with aortic stenosis;

• Initial results from trials comparing TAVI to SAVR in low-risk population show non-inferiority;

• However, low clinical risk is different from anatomical and procedural risk for TAVI;

• Specific features relevant to the TAVI procedure are not included in common risk score calculators;

• Awareness of TAVI limitations should prompt tailored procedural strategies and appropriate device selection to prevent and mitigate the risks.

Declaration of interest

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.

Reviewer disclosures

A reviewer on this manuscript has disclosed they are a proctor for THV program of Edwards Lifesciences. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.