Dr. Volkmar Falk,
The session served the purpose to discuss major issues and complications of TAVI procedures and to understand future indications of TAVI. Alec Vahanian highlighted the importance of pre-procedural risk assessment for selecting patients for TAVI. Standard scoring systems assess patient related factors that have an impact on mortality or address important comorbidities. While commonly applied these risk factors do not predict procedure related complications such as AV-block, paravalvular leakage or vascular injury, all of which may impair the long-term outcome after TAVI. Prof. Vahanian emphasized the importance of advanced imaging modalities for screening and implant selection to minimize the risk of procedure related complications. He also highlighted the 2012 ESC/EACTS Guidelines for Heart Valve Disease, that clearly restrict the indication for TAVI to a high risk population. Before TAVI can be applied to lower risk populations, randomized trials are needed, said Vahanian. Olaf Wendler from London addressed the various access options that are currently available. While most of the TAVI implants are performed transfemoral, this default approach is not justified based on the available data. In most risk adjusted analysis or propensity matched analysis no difference for major outcomes between transapical and transfemoral access can be found. He stressed the fact, that the transapical access is the only access that allows for an antegrade, direct approach to the aortic valve. Wendler also discussed the Pros and Cons of the subclavian approach as well as the more recently developed direct aortic access. Martin Thomas focused on one major complication: stroke. He demonstrated the potential causes such as ballon valvuloplasty, passage of stiff catheters along the often calcified aortic arch and valve implantation. The incidence of stroke in the more recent publications is lower than previously reported which is probably due to the use of more flexible and smaller systems. For the Sapien Valve implantation without prior valvuloplasty is possible which may have an impact on the embolization rate. He also discussed the potential of shielding devices and deflectors that should redirect emboli from the arch downstream but data to support any clinical benefit of these devices is still lacking. The importance of new lesions visible on MRI without clinical abnormalities remains controversial. Thomas emphasized the need for uniform definitions and recommended the use of the VARC criteria for reporting results. Pieter Kappetein discussed the durability of valves used for TAVI. He demonstrated the excellent performance of transcatheter valves in preclinical fatigue tests demonstrating similar results as standard biological valves. This applies both to the leaflets and the stents. He also emphasized the fact that the failure rate of contemporary transcatheter valves due to structural failure in clinical trials is very low. Despite these findings, long-term follow-up data are still lacking and will only be available after trials in a younger population. Finally, Nicola Piazza discussed the rationale for applying TAVI to a younger and lower rsik population. He pointed out that in many centers TAVI has evolved as a routine procedure and that the results of recent trials show improved outcomes demonstrating the safety of the approach. The incidence of paravalvular leak however remains a concern especially for implantation in younger patients. Based on the recent outcomes contemporary trials in younger and lower risk patients such as SURTAVI are justified, said Piazza and discussed the trial designs in this context.
Transcatheter aortic valve implantation (TAVI): current issues
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