Elsevier

Cardiology Clinics

Volume 38, Issue 1, February 2020, Pages 115-128
Cardiology Clinics

Transcatheter Aortic Valve Replacement: Procedure and Outcomes

https://doi.org/10.1016/j.ccl.2019.09.007Get rights and content

Section snippets

Key points

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    Transcatheter aortic valve replacement (TAVR) was initially only used in patients with severe symptomatic aortic stenosis and prohibitive risk for surgical aortic valve replacement (SAVR).

  • •

    Subsequently, this procedure was extended to patients with high and intermediate surgical risk and was reported as superior to SAVR in low-risk patients.

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    Procedural outcomes have been improved owing to assessments by heart teams, the development of safer devices and delivery systems, and a better knowledge in

Randomized trials of transcatheter aortic valve replacement versus surgical aortic valve replacement

After years of ex vivo testing and animal implantation of transcatheter heart valves (THVs), the first-in-human TAVR was performed by Cribier and colleagues1 in Rouen, France, in 2002. This first THV consisted of 3 bovine pericardial leaflets mounted within a tubular, slotted, stainless steel, balloon-expandable stent,1 and was implanted in a 57-year-old man with severe bicuspid AS, severely depressed left ventricle ejection fraction, and cardiogenic shock who was inoperable.1

After this first

Guidelines for the selection of transcatheter aortic valve replacement versus surgical aortic valve replacement

The strong body of evidence established by the randomized trials presented earlier have formed the basis of the current guidelines recommendations for the selection of TAVR versus SAVR (Fig. 1). In patients considered to have symptomatic severe AS and to be potential candidates for TAVR, the guidelines strongly recommend (class I) an evaluation of these patients by the heart team to confirm the indication of aortic valve replacement (AVR) and determine the optimal type of AVR: SAVR or TAVR (see

Type of Transcatheter Heart Valve

Historically, 2 main types of THV systems have been used: balloon-expandable (SAPIEN, SAPIEN XT, SAPIEN 3, Edwards Lifesciences; Irvine, CA) and self-expanding (CoreValve, EVOLUT R, EVOLUT PRO; Medtronic, Inc., Minneapolis, MN, USA) THVs (see Fig. 2; Fig. 3). Other catheter-based delivery systems have also been recently developed: inflatable rings (Direct Flow THV; Direct Flow Medical), and mechanically expandable THV (Lotus THV, Boston Scientific). During the TAVR evolution, the design and

Echocardiographic outcomes

Transvalvular pressure gradients and aortic valve areas are generally better with TAVR versus SAVR and within SAVR with self-expanding THVs compared with balloon-expandable THVs (Table 2).4,5,11,14 The superiority of self-expanding THVs seems to be related to the supra-annular position of the valve leaflets. This advantage is not present with the last iteration of the Edwards devices (SAPIEN 3), which have shown higher aortic mean gradient and less aortic valve area compared with surgical

All-Cause and Cardiovascular Mortality

A recent meta-analysis by Barbanti and colleagues40 of 37 studies and including 10,822 patients with high or intermediate risk undergoing transfemoral TAVR with new THV generations reported a 30-day all-cause and cardiovascular death rate of 2.2% (95% confidence interval [CI], 1.6%–2.8%) and 1.6% (95% CI, 0.9%–2.3%), respectively. These rates were even lower in low-risk patients,51,52 and were less than or equal to 0.5% in the recent randomized trials (Table 3).4,5 In high-risk patients and in

Future perspectives

The indications for TAVR are rapidly expanding. Recent registries of TAVR in patients with a bicuspid aortic valve have reported excellent results, which are as good as TAVR in patients with a tricuspid valve.73 However, TAVR is still contraindicated in patients with a bicuspid aortic valve and large aortic annulus and/or with concomitant aortopathy requiring surgical intervention.

The ongoing EARLY-TAVR (Evaluation of Transcatheter Aortic Valve Replacement Compared to SurveiLance for Patients

Summary

TAVR has expanded rapidly since the first-in-human aortic THV implantation in 2002. In the near future, TAVR may become the treatment of choice for all patients with symptomatic severe AS who require intervention. Procedural outcomes have been improved owing to assessment by the heart teams, the development of safer devices and delivery systems, and better knowledge of the implantation techniques and patient management after the TAVR. However, long-term durability of THV remains to be confirmed

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    Disclosure: Dr E. Salaun has nothing to disclose. Dr P. Pibarot received research grants from Edwards Lifesciences and Medtronic for echo corelab analyses in transcatheter aortic valve replacement. Dr J. Rodés-Cabau has received institutional research grants from Edwards Lifesciences.

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