The IX t h Makassed Medical Congress - American University of Beirut

T h e I X t h M a k a s e d M e d i c a l C o n g r e s s
Transcatheter Aortic Valve Implantation
Samir R. Kapadia, MD
E. Murat Tuzcu, MD
Corresponding author
E. Murat Tuzcu, MD
Department of Medicine, Cleveland Clinic,
9500 Euclid Avenue, J2-3, Cleveland, OH 44195, USA.
E-mail: Tuzcue@ccf.org
Current Treatment Options in Cardiovascular Medicine 2009, 11:467–475
Current Medicine Group LLC ISSN 1092-8464
Copyright © 2009 by Current Medicine Group LLC
Opinion statement
Aortic stenosis is the most important valvular heart disease affecting the elderly
population. Surgical aortic valve replacement is the mainstay of treatment, although
a substantial number of patients are considered high risk for surgery. Many of these
patients do not undergo surgery and have poor outcomes from medically treated
symptomatic, severe aortic stenosis. Transcatheter aortic valve implantation (TAVI)
provides a promising treatment option for some of these patients. Several devices
are under investigation. The Edwards Sapien valve (Edwards Lifesciences, Irvine,
CA) and the CoreValve (Medtronic, Minneapolis, MN) have the largest human experience
to date. Initial data suggest that these devices have an acceptable safety
profi le and provide excellent hemodynamic relief of aortic stenosis. The Edwards
Sapien valve is currently under investigation in the United States in the PARTNER
(Placement of Aortic Transcatheter Valve) trial in high-risk surgical or inoperable patients;
TAVI is available for clinical use in both Canada and Europe. TAVI is not used
in low- or intermediate-risk surgical patients; however, future studies may prove
its applicability in these subsets. The major complications of TAVI include access
site–related problems and device malpositioning/migration. There are several newgeneration
prosthetic valves and delivery systems designed to be low profi le and repositionable.
Technical advances and refi nement of the implantation methods may
make TAVI even safer and ultimately a better treatment option, not only for patients
with high surgical risk but also for those with moderate or low risk.
Introduction
Valvular heart disease has a signifi cant impact on
cardiovascular mortality and morbidity [1–3]. Aortic
stenosis (AS) is the most common valvular lesion in
the aging population, with a prevalence of 4.6% in
adults ≥ 75 years of age [2–4]. The advancing age of
the population, combined with the lack of pharmacologic
therapies to prevent, halt, or effectively slow the
progression of AS, has led to an even greater burden of
this disease in developed countries [1–3].
Surgical aortic valve replacement (SAVR) is the recommended
treatment for patients with symptoms [5].
After the onset of symptoms, average survival may be
as brief as 1 to 3 years without SAVR [5–9]. Within the
United States, more than 50,000 aortic valve replacements
(AVRs) are performed annually for severe AS.
Many patients with severe symptomatic AS do not
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undergo surgery for various reasons. Some are not
referred for surgery because of comorbidities or patient
preference; others are deemed inoperable by the surgeon
because of the presence of coexisting illnesses. This issue
is particularly the case with the elderly. In the Euro Heart
Survey on valvular heart disease, 33% of patients with
severe symptomatic AS did not undergo surgery [10].
Other studies similarly have shown that 27% to 41%
of patients with severe symptomatic AS do not undergo
SAVR [9,11–13]. The advent of transcatheter aortic
valve implantation (TAVI) provides a unique treatment
option for some of these patients [14–19,20•,21].
SAVR remains the gold standard of treatment for
patients with low and intermediate surgical risk. However,
the surgical risk is diffi cult to judge at times because
several subjective variables may play critical roles in