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Transcatheter aortic valve implantation: current and future approaches

Nature Reviews Cardiology volume 9, pages 15–29 (2012)Cite this article

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Abstract

The first human transcatheter aortic valve implantation (TAVI) in 2002, and several subsequent single-center series, showed the feasibility of this new approach for the treatment of patients with severe aortic stenosis who were considered to be at very high or prohibitive surgical risk. More-recent multicenter registries have confirmed the safety and efficacy of this procedure, despite a very-high-risk patient profile. Moreover, the randomized, controlled PARTNER trial has confirmed both the superiority of TAVI over medical treatment in patients not considered to be candidates for standard surgical aortic valve replacement and the noninferiority of TAVI compared with surgical aortic valve replacement in high-risk patients. The hemodynamics of transcatheter valves are usually excellent, although residual paravalvular aortic regurgitation (usually trivial or mild) is frequent. Stroke, major vascular complications, and conduction disturbances leading to permanent pacemaker implantation remain among the most-concerning periprocedural complications of TAVI. Nevertheless, promising preliminary data exist for long-term outcomes following TAVI, 'valve-in-valve' TAVI for surgical prosthesis dysfunction, and for the treatment of lower-risk patients. Improvements in transcatheter valve technology, optimization of procedural and midterm results, and confirmation of long-term durability of transcatheter valve prostheses will determine the expansion of TAVI towards the treatment of a broader spectrum of patients.

Key Points

  • Transcatheter aortic valve implantation (TAVI) represents a less-invasive strategy than surgical aortic valve replacement (SAVR) for the treatment of severe symptomatic aortic stenosis

  • The transfemoral approach is usually the first option for TAVI; transapical, subclavian, axillary, and transaortic routes are alternative approaches

  • TAVI is currently the treatment of choice for patients not considered to be candidates for SAVR, and a proven alternative for those considered to be at high surgical risk

  • Transcatheter valves are associated with excellent hemodynamic results, usually with concomitant improvements in the patient's functional status and quality of life; however, minor residual aortic regurgitation occurs in many patients

  • Periprocedural stroke, vascular and conduction disturbance complications, occurrence of moderate or severe paravalvular aortic regurgitation, relatively high midterm mortality, and valve durability beyond 3-year follow-up are unresolved issues in TAVI

  • The 'valve-in-valve' treatment of surgical prosthesis dysfunction and the treatment of intermediate-risk patients are two of the most-important fields for the development of TAVI in the near future

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Figure 1: Photographs of the transcatheter prosthetic valves currently used for transcatheter aortic valve implantation.
Figure 2: Pre-procedural work-up in patients with severe aortic stenosis who are candidates for a TAVI procedure with the Edwards SAPIEN XT® (Edwards Lifesciences Corporation, Irvine, CA, USA) valve or CoreValve® (Medtronic CV Luxembourg S.a.r.l., Luxembourg) systems.
Figure 3: Approaches used for transcatheter aortic valve implantation.
Figure 4: Valve implantation of balloon-expandable and self-expandable transcatheter valves.
Figure 5: Valve hemodynamics following TAVI with the balloon-expandable Cribier–Edwards and Edwards SAPIEN® (Edwards Lifesciences Corporation, Irvine, CA, USA) valve (on the basis of the work of Clavel et al.95).
Figure 6: Changes in LVEF after TAVI and SAVR in patients with severe aortic stenosis and low LVEF (on the basis of the work of Clavel et al.101).
Figure 7: Images of emerging transcatheter valve technology (valves with first-in-man data).

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Acknowledgements

The author wishes to thank Mélanie Côté, MSc, (Quebec Heart and Lung Institute, Quebec City, QC, Canada) for her outstanding work in the preparation of tables and figures.

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  1. Quebec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Quebec City, G1V 4G5, QC, Canada

    Josep Rodés-Cabau

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J. Rodés-Cabau declares that he is a consultant for Edwards Lifesciences and St. Jude Medical.

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Rodés-Cabau, J. Transcatheter aortic valve implantation: current and future approaches. Nat Rev Cardiol 9, 15–29 (2012). https://doi.org/10.1038/nrcardio.2011.164

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