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Matching patients with the ever-expanding range of TAVI devices

Nature Reviews Cardiology volume 14, pages 615–626 (2017)Cite this article

Subjects

Key Points

  • Transcatheter aortic valve implantation (TAVI) is now a viable therapeutic option for a wide variety of patients, through its numerous vascular access approaches and different valve systems

  • The process of selecting the appropriate TAVI device and procedure for each individual patient requires a comprehensive and multidisciplinary approach

  • Numerous clinical situations require special considerations, including the presence of low coronary ostia, pre-existing mitral prostheses, bicuspid aortic valves, severe left ventricular outflow tract calcification, and degenerative bioprosthetic valve disease

  • As techniques evolve to treat younger patients and lower-risk populations, issues associated with procedural safety, such as risk of neurological events, paravalvular aortic regurgitation, and permanent pacemaker placement, must be addressed with newer-generation devices

Abstract

Transcatheter aortic valve implantation (TAVI) has become a widely accepted strategy for the treatment of aortic stenosis in patients at intermediate, high, or prohibitive surgical risk. After >1 decade of innovation and clinical trial experience, the available technology for TAVI has grown enormously, and now includes a myriad of vascular access approaches and innovative valve designs. As a result, the range of patients who can benefit from these advances continues to grow rapidly. Furthermore, given the improved safety profile and clinical success of current-generation devices in randomized trials, the use of TAVI among even low-risk populations is justified in current trials. With the rapid dissemination and expansion of this technology, operators need to have a comprehensive understanding of how to select the appropriate procedural approach for each individual patient. In this Review, we detail the current evidence for TAVI among different patient populations, discuss the different vascular access approaches currently in use, and explore differences in design features among currently available and investigational valve systems. Furthermore, we provide an overview of important considerations for special patient populations, such as those with existing mitral prostheses, bicuspid aortic stenosis, isolated aortic regurgitation, or severe left ventricular outflow tract calcification.

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Figure 1: Flow chart for the multidisciplinary evaluation of high-risk patients with aortic stenosis.
Figure 2: All-cause mortality in pivotal TAVI/SAVR studies grouped by risk category.
Figure 3: Various vascular access approaches for transcatheter aortic valve implantation (TAVI).
Figure 4: Commercially available and investigational devices for transcatheter aortic valve implantation.
Figure 5: TAVI with a self-expanding valve in a patient with severe left ventricular outflow tract (LVOT) calcification.

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Authors and Affiliations

  1. Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, Ohio, USA

    Brandon M. Jones, Amar Krishnaswamy, Wael A. Jaber & Samir R. Kapadia

  2. Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi, UAE

    E. Murat Tuzcu

  3. Department of Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, Ohio, USA

    Stephanie Mick & Lars G. Svensson

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Contributions

B.M.J. and S.R.K. researched data for the article. B.M.J., A.K., S.M., W.A.J., L.G.S., and S.R.K. contributed substantially to the discussion of content. B.M.J., A.K., and S.R.K. wrote the manuscript. All authors reviewed and edited the manuscript before submission.

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Correspondence to Samir R. Kapadia.

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Competing interests

E.M.T. has received travel fees from Edwards Lifesciences, and is an unpaid member of the executive committee for the PARTNER trial. W.A.J. has received fees from Edwards Lifesciences for CoreLab work in the PARTNER trial. L.G.S. is an unpaid member of the executive committee for the PARTNER trial. S.R.K. is an unpaid member of the executive committee for the Lotus, Portico, and PARTNER trials. The other authors declare no competing interests.

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Jones, B., Krishnaswamy, A., Tuzcu, E. et al. Matching patients with the ever-expanding range of TAVI devices. Nat Rev Cardiol 14, 615–626 (2017). https://doi.org/10.1038/nrcardio.2017.82

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