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Summary
Introduction
Patient selection
Potential candidates to transcatheter aortic valve
implantation (TAVI) are mainly high-risk and elderly
symptomatic patients with severe aortic stenosis. At
present, the use of TAVI in young patients, at low
surgical risk, patients with long life expectancy, and in
asymptomatic patients is strongly discouraged
because of the uncertainty regarding long-term
durability and clinical results compared to surgery.
Patients with life expectancy shorter than one year
should also not be considered for TAVI. Surgical risk
should be assessed by a combination of scores and by
clinical judgment. To be considered for TAVI using the
SAPIEN THV transfemoral approach, annular diameter
of the native valve should be between 18 mm and
24 mm, and the iliac vessel anatomy should be
favorable for introduction of the given delivery
system.
Surgical technique
Screening process
Selection of patients is the most critical step of the
procedure. It includes: confirmation of severity of
aortic stenosis (by means of Doppler
echocardiography, or rarely by catheterization, Photo
3), analysis of aortic valve and root anatomy (by a
combination of angiography, echocardiography and
MDCT scanning, Photo 4) and analysis of iliofemoral
access (by angiography and MDCT, Photo 5). Annular
diameter has to be precisely determined, to avoid
valve embolization and perivalvular leakage. Annular
diameter is measured by transesophageal,
transthoracic echocardiography and by MDCT (Photo
6). Iliofemoral anatomy is analyzed by angiography
and/or MDCT scanning to determine size (Photo 7),
presence of calcifications (Photo 8) and tortuosity
(Photo 9).
Results
Top
Summary
Introduction
Surgical technique
Results
Discussion
References
Initial published data on procedural mortality and
morbidity have demonstrated acceptable preliminary
results in a high-risk environment. Webb et al. [3]
published their TAVI experience on 50 symptomatic
patients with severe aortic stenosis. Valve
implantation was successful in 86% of patients.
Intraprocedural mortality was 2%. Discharge home
occurred at a median of five days (interquartile range,
4–13). Mortality at 30 days was 12% in patients in
whom the logistic European System for Cardiac
Operative Risk Evaluation risk score was 28%. With
experience, procedural success increased from 76% in
the first 25 patients to 96% in the second 25
(P=0.10), and 30-day mortality fell from 16 to 8%
(P=0.67). Mild paravalvular regurgitation was
common but was well tolerated. After valve insertion,
there was a significant improvement in left ventricular
ejection fraction (P<0.0001), mitral regurgitation
(P=0.01), and functional class (P<0.0001).
Improvement was maintained at one year. Structural
valve deterioration was not observed with a median
follow-up of 359 days.
Discussion
Top
Summary
Introduction
Surgical technique
Results
Discussion
References
TAVI is a new technology. Self-expanding and balloon
expanding valves are currently implanted in Europe.
At the moment TAVI are performed only in selected
centers with a multidisciplinary approach. Their role in
the management of aortic stenosis is evolving.
Initially TAVI was only performed in end-stage
patients. Today TAVI is performed also in high-risk
patients. Before TAVI being proposed for current
surgical candidates, safety efficacy and durability of
the implants have to be determined on a large scale.
Footnotes
1
Consultant for Edwards Lifesciences LLC.
References
Top
Summary
Introduction
Surgical technique
Results
Discussion
References
1. Iung B, Baron G, Butchart EG, Delahaye F,
Gohlke-Bärwolf C, Levang OW, Tornos P,
Vanoverschelde JL, Vermeer F, Boersma E,
Ravaud P, Vahanian A. A prospective survey of
patients with valvular heart disease in Europe:
the Euro Heart Survey on Valvular Heart Disease.
Eur Heart J 2003;24:1231–1243.
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Francesco Maisano
Ottavio Alfieri
Antonio Colombo
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