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Expanding the indications for transcatheter aortic valve implantation

Abstract

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of symptomatic severe aortic valve stenosis. Current guidelines recommend TAVI in patients at increased operative risk of death. Advanced imaging planning, new transcatheter valve platforms, procedure streamlining and growing operator experience have improved procedural safety and bioprosthetic valve performance. As a result, TAVI has been explored for other indications. Two randomized trials published in 2019 to assess TAVI in patients with symptomatic severe aortic stenosis at low operative risk have set the stage for a new wave of indications. In younger and low-risk patients, TAVI had an early safety benefit over surgical aortic valve replacement and was associated with faster discharge from hospital and recovery and fewer rehospitalizations. In patients with symptomatic severe aortic stenosis, TAVI has now been explored across the entire spectrum of operative risk, from inoperable to low-risk populations, in properly designed, randomized clinical trials, although data on the long-term durability of these valves are lacking. The use of TAVI in severe bicuspid aortic valve stenosis, asymptomatic severe aortic stenosis, moderate aortic stenosis in combination with heart failure with reduced ejection fraction, and isolated pure aortic regurgitation is now under investigation in clinical trials. In this Review, we provide our perspective on these evolving indications for TAVI, discuss relevant available data from clinical trials, and highlight procedural implications and caveats of new and future indications.

Key points

  • Transcatheter aortic valve implantation (TAVI) is an accepted treatment option for elderly patients with symptomatic severe degenerative tricuspid aortic valve stenosis across the entire spectrum of operative risk.

  • Long-term durability of transcatheter valves is unknown and requires further research.

  • The use of TAVI with new-generation devices seems attractive for bicuspid aortic valve stenosis, but sizing algorithms might need to be modified.

  • Timing to proceed with TAVI and procedural safety are crucial in truly asymptomatic patients with severe calcified aortic stenosis.

  • TAVI might complement afterload reduction with medical therapy in patients with heart failure and moderate aortic stenosis.

  • Treatment for pure aortic regurgitation might demand dedicated transcatheter valve designs to secure device anchoring in noncalcified aortic roots.

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Fig. 1: Evolution of TAVI indications.
Fig. 2: Studies on TAVI versus SAVR in patients at different surgical risk and of similar age.
Fig. 3: Flowchart of the design of the EARLY TAVR study.
Fig. 4: Design of the TAVR UNLOAD trial.

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Z.R., N.E.F., M.B.L. and N.M.V.M. researched data for the article; Z.R., N.E.F. and N.M.V.M. wrote the manuscript; all the authors discussed the content of the manuscript and reviewed and edited it before submission.

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Correspondence to Nicolas M. Van Mieghem.

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Rahhab, Z., El Faquir, N., Tchetche, D. et al. Expanding the indications for transcatheter aortic valve implantation. Nat Rev Cardiol 17, 75–84 (2020). https://doi.org/10.1038/s41569-019-0254-6

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