Expanding indications for transcatheter aortic valve replacement

Abstract

Transcatheter aortic valve replacement (TAVR) has emerged as an accepted indication for non-operable patients with severe symptomatic native aortic valve stenosis (AS) and as a reasonable alternative for high-risk surgical AS patients. Nonetheless, the safety and efficacy of performing TAVR in several other potential indications are yet unclear. In the present manuscript the authors review the current evidence supporting TAVR for other potential indications than the typical high-risk/non-operable AS patients, providing updated results of the main clinical trials and registries exploring these particular indications. Finally, the authors provide practical recommendations for TAVR in each of these conditions.

Keywords::

• aortic regurgitation
• aortic stenosis
• bicuspid aortic stenosis
• moderate risk
• transcatheter aortic valve replacement
• valve-in-valve

Financial & competing interests disclosure

G Maluenda is a proctor for Edwards Lifesciences. 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.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Transcatheter aortic valve replacement (TAVR) is an accepted and an approved indication for severe high-risk/inoperable AS population supported by PARTNER IA and IB trial and Extreme Risk CoreValve Cohort study.

• There is a natural paradigm shift to treat lower risk aortic stenosis (AS) patients among large and experienced TAVR centers.

• Large nonrandomized clinical series support TAVR being safer and as affective as surgical aortic valve replacement in moderate-risk population.

• Two large randomized clinical trials, SURTAVI and PARTNER IIA, will provide very important and conclusive evidence to define the role of TAVR in moderate-risk AS population.

• Valve-in-valve procedure for failed bioprosthetic valves in aortic position is a reasonable alternative to reoperation for high-risk surgical candidates with concerns that include malposition, coronary occlusion and elevated postprocedural gradients.

• Most of bicuspid severe AS patients are currently possible to treat if device accommodating the aortic annulus and a raphe is present on cardiac computed tomography.

• Pure severe aortic regurgitation and truly bicuspid AS can be treated with self-expandable transcatheter heart valve at a higher risk of device embolization. This population may require deployment of a dedicated device.

Notes