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Challenging clinical scenarios in aortic stenosis

Valvular Heart Diseases


Transcatheter aortic valve implantation (TAVI) is accepted as a suitable treatment option for patients with severe symptomatic aortic stenosis (AS) unsuitable or high-risk for surgical aortic valve replacement (sAVR). Since Alain Cribier pioneered the first TAVI in 2002, reliable devices and techniques have been developed and the procedure has become technically reproducible and safe in experienced hands.
This has stimulated discussions to further widen the indication for TAVI to the group of patients with only intermediate risk for sAVR and also to treat patients with certain cardiac morbidities, such as concomitant mitral stenosis or paradoxical low-flow/low-gradient.
Dr Prendergast from Oxford, UK highlighted that there is currently an increasing number of intermediate risk patients treated using TAVI, particularly in countries where funding of the procedures is less of an issue, such as in Germany and Switzerland. Results of these early experiences are sometimes not convincing and direct comparison to outcome of gold-standard sAVR is not available. As a logical consequence, decisions on treatment in intermediate risk patients with AS should currently be made only by the heart team (cardiologists, cardiac surgeons and additional sub-specialists as needed) and patients treated should ideally be enrolled in various trials (eg Surtavi, the UK TAVI trial and Partner II) and registries suitable to assess and follow up their outcome.
Although there is lots of evidence supporting decisions around the treatment of patients with AS and concomitant mitral regurgitation, the evidence for patients with mitral stenosis is poor. Dr Brochet from Paris, France highlighted the challenging diagnostics and discussions in this patient group. Using a patient case in whom the aortic valve was first treated using TAVI, he demonstrated that patient recovery may be incomplete due to the persistent mitral obstruction. In their case with severe complete calcification of the mitral valve ring, transcatheter implantation of a Sapien® transcatheter heart valve (Edwards Lifesciences, Irvine, CA, USA) into the native mitral valve was performed successfully, a very new approach which may be promising for the future.
Patients with paradoxical low-flow/low-gradient constellation are nowadays more often diagnosed with AS since Dr Pibarot from Quebec, Canada described this entity some years ago. Dr Pierard from Liege, Belgium highlighted the diagnostic tools available to come to the diagnosis in these patients. Currently available outcome demonstrates that although their perioperative risk is higher compared to patients with AS and normal flow/gradients, they benefit greatly from sAVR or TAVI.
In summary, this session offered insights into the newest diagnostics and treatments for patients with AS and highlighted that best outcome can be provided by a functional highly-skilled multidisciplinary heart team.

 

References


Session Title: Challenging clinical scenarios in aortic stenosis

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.