Simplification and optimization of transcatheter aortic valve implantation - fast-track course without compromising safety and efficacy.

Transcatheter aortic valve implantation (TAVI) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis. Ageing of the Western and Asian population and expansion of indications for TAVI will lead to a substantial increase in the number of TAVI procedures performed worldwide within the next decades. In line with the maturation of TAVI over the past few years, there has also been a significant simplification and optimisation of the TAVI procedure. A minimalist TAVI procedure and fast-track TAVI course have been shown to have distinct advantages over the more traditional TAVI approach. The aim of this manuscript is to discuss strategies of TAVI simplification and optimization, with special focus on fast-track TAVI, without compromising safety and efficacy.

Transcatheter Aortic Valve Replacement With Early- and New-Generation Devices in Bicuspid Aortic Valve Stenosis.

BACKGROUND: Few studies have evaluated the clinical outcomes of transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve stenosis (AS). Particularly, limited data exist comparing the results of TAVR with new-generation devices versus early-generation devices. OBJECTIVES: This study sought to evaluate the clinical outcomes of TAVR for bicuspid AS with early- and new-generation devices. METHODS: The Bicuspid TAVR Registry is an international multicenter study enrolling consecutive patients with bicuspid AS undergoing TAVR between April 2005 and May 2015. RESULTS: Of 301 patients, 199 patients (71.1%) were treated with early-generation devices (Sapien XT [Edwards Lifesciences Corporation, Irvine, California]: n = 87; CoreValve [Medtronic, Minneapolis, Minnesota]: n = 112) and 102 with new-generation devices (Sapien 3 [Edwards Lifesciences Corporation]: n = 91; Lotus [Boston Scientific Corporation, Marlborough, Massachusetts]: n = 11). The mean Society of Thoracic Surgeons score was 4.7 ± 5.2 without significant differences between groups (4.6 ± 5.1 vs. 4.9 ± 5.4; p = 0.57). Overall, all-cause mortality rates were 4.3% at 30 days and 14.4% at 1 year. Moderate or severe paravalvular leak was absent and significantly less frequent with new-generation compared to early-generation devices (0.0% vs. 8.5%; p = 0.002), which resulted in a higher device success rate (92.2% vs. 80.9%; p = 0.01). There were no differences between early- and new-generation devices in stroke (2.5% vs. 2.0%; p > 0.99), life-threatening bleeding (3.5% vs. 2.9%; p > 0.99), major vascular complication (4.5% vs. 2.9%; p = 0.76), stage 2 to 3 acute kidney injury (2.5% vs. 2.9%; p > 0.99), early safety endpoints (15.1% vs. 10.8%; p = 0.30), and 30-day all-cause mortality (4.5% vs. 3.9%; p > 0.99). CONCLUSIONS: The clinical outcomes of TAVR in patients with bicuspid AS were favorable. New-generation devices were associated with less paravalvular leak and, hence, a higher device success rate than early-generation devices. (The Bicuspid Aortic Stenosis Following Transcatheter Aortic Valve Replacement Registry [Bicuspid TAVR]; NCT02394184).

Choice of Treatment for Aortic Valve Stenosis in the Era of Transcatheter Aortic Valve Replacement in Eastern Denmark (2005 to 2015).

OBJECTIVES: The aim of this study was to evaluate the choice of treatment for severe aortic valve stenosis in the era of transcatheter aortic valve replacement (TAVR) in Eastern Denmark. BACKGROUND: Until the early 21st century, the only therapeutic option for aortic valve stenosis was surgical aortic valve replacement (SAVR), but this has changed with the introduction of TAVR. METHODS: Using the East Denmark Heart Registry, the evolution of AVR over time was studied for the period 2005 to 2015. RESULTS: TAVR has since its introduction in 2007 seen steady growth, with currently more than 35% of AVR procedures-and 45% of isolated AVR procedures-being performed by transcatheter-based technology. The number of SAVR procedures remained rather stable over the study period and even saw a slight decline since 2012-there was a marked decrease in the age at which surgical bioprostheses are considered appropriate. The age profile of TAVR patients remained unchanged over the study period, with a recent trend toward more low- and intermediate-risk patients. Currently, patients age ≥80 years and/or with a Society of Thoracic Surgeons (STS) surgical risk score >6 are automatically referred for TAVR, and one-half of patients age 70 to 80 years with an STS risk score of 4 to 6 are treated with TAVR. CONCLUSIONS: The number of TAVR procedures has increased steadily in recent years, with a TAVR penetration rate of 35% in 2015 and close to 45% when considering isolated AVR. The number of SAVR procedures remained stable over the study period, and surgical bioprostheses are currently used at a much younger age than in 2005.

Anatomical challenges for transcatheter mitral valve intervention.

Following the success of transcatheter aortic and pulmonary valve implantation, there is a large interest in transcatheter mitral valve interventions to treat severe mitral regurgitation (MR). With the exception for the MitraClip™ (Abbott, Abbott Park, IL, USA) edge-to-edge leaflet plication system, most of these transcatheter mitral valve interventions are still in their early clinical or preclinical development phase. Challenges arising from the complex anatomy of the mitral valve and the interplay of the mitral apparatus with the left ventricle (LV) have contributed to a more difficult development process and mixed clinical results with these novel technologies. This review aims to discuss the several anatomical aspects and challenges related to transcatheter mitral valve intervention--the relevant anatomy will be reviewed in relation to specific requirements for device design and procedural aspects of transcatheter mitral valve interventions. To date, experience with these novel therapeutic modalities are still limited and resolution of many challenges are pending. Future studies have to evaluate for whom the transcatheter approach is a feasible and preferred treatment and which patients will benefit from either transcatheter mitral valve repair or replacement. Nevertheless, technological developments are anticipated to drive the transcatheter approach forward into a clinically feasible alternative to surgery for selected patients with severe MR.