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Transcatheter aortic valve implantation: an ABC for the general cardiologist

Valvular Heart Diseases

Professor Alain Cribier, one of the inventors of transcatheter aortic valve implantation (TAVI), presented his incredible adventure, and the hostility he had to face. “One more study idea, I heard”… but he was convinced that he was right, and in 2002, he implanted the first percutaneous aortic valve and proved the concept of TAVI.

When TAVI is being considered, several questions should be answered:
1- Is aortic stenosis (AS) truly severe and the patient symptomatic?
2- Is the patient a good clinical candidate? TAVI is, for now, indicated in patients considered at high-risk or contra-indicated for surgery with at least one year of life expectancy.
In this very sick population, when a TAVI is “futile” (too late or not reasonable due to severe cardiac or non- cardiac comorbidities, frailty or poor mobility), this presents a difficult problem. No score is perfect, and in the end, the final decision should come from the clinical judgment of experienced specialists including geriatricians. On the other hand, the line between intermediate and high-risk patients is also fine, and ongoing prospective trials will hopefully addressed this question.
3- Is TAVI technically feasible? Imaging is crucial; and cardiac, valvular and vascular assessment should combine echocardiography, computed tomography and angiography. 

TAVI faces several challenges, mainly vascular complications, stroke, paravalvular aortic regurgitation and conduction disorders. Improvements in prosthetic technology, and in enabling devices such as cerebral embolic protection devices, and the development of imaging before and during the procedure (fusion images) will improve procedural success rate. Finally, the question of the durability remains open.
The natural history prognosis of untreated patients with symptomatic severe AS is dramatic and these patients should be systematically considered for intervention. In the EuroHeart survey, 1/3 of patients with severe symptomatic AS were not referred to surgery, mostly for unfounded reasons. With the development of TAVI (and of surgery), one would expect the number of untreated patients to have decreased.

It has been a long road since the first-in-man procedure in 2002… More than 80 000 patients have been implanted worldwide and TAVI has revolutionized our clinical management. However, this intervention should not be excessively minimized and TAVI should be performed in experienced centers with surgical facilities and by experienced physicians organized in a heart team.


Session Title: Transcatheter aortic valve implantation: an ABC for the general cardiologist

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.