The only effective treatment for severe aortic stenosis is replacement of the diseased aortic valve1
Learn more about the evaluation of patients with severe aortic stenosis for transcatheter aortic valve implantation (TAVI), the role of the Heart Team and the impact of the 2017 ESC/EACTS (European Society of Cardiology/European Association for Cardio-Thoracic Surgery) Guidelines.
The role of the Heart Team
According to the 2017 ESC/EACTS Guidelines for the management of valvular heart disease, aortic valve replacement (AVR) is indicated in patients with severe symptomatic aortic stenosis and in cases of low-flow, low-gradient aortic stenosis, unless unlikely to improve quality of life or survival.1 Surgical AVR (sAVR) should also be considered in asymptomatic patients where patients meet the criteria for this treatment modality, as defined in the 2017 ESC/EACTS Guidelines.1
Aortic valve interventions should only be performed in centres with collaborating cardiology and cardiac surgery departments. Once diagnosed, your referral of patients to a Heart Valve Centre ensures that the multidisciplinary Heart Team, with expertise in valvular heart disease, will be able to determine which type of intervention is most suitable. This collaborative decision-making process should also include the patient, their family and the referring cardiologist.1
When is TAVI appropriate?
The decision to utilise sAVR or TAVI is made by the Heart Team. It is dependent on estimated surgical risk and based on a patient’s clinical characteristics, anatomical and technical aspects as well as any coexisting cardiac conditions that may require concomitant intervention.1 According to the 2017 ESC/EACTS Guidelines, the Heart Team may consider TAVI or sAVR as an appropriate option in patients at increased surgical risk, with TAVI favoured in patients aged ≥75 years. In patients who are unsuitable or at high risk for open heart surgery due to comorbidities, TAVI is the recommended treatment option.1
For up-to-date information on recommended intervention according to the 2017 ESC/EACTS Guidelines for the management of Valvular Heart Disease:
How is the TAVI procedure performed?
Year-on-year, the use of TAVI in patients with severe aortic stenosis is increasing. In Europe, this growth resulted in 39,931 TAVI procedures performed in 2016, compared with 10,660 in 2012 2 and following expansion of the patient cohort indicated for treatment with transfemoral TAVI,1 this is likely to increase further in the coming decade, potentially becoming the standard of care for many patients with severe aortic stenosis.3
The TAVI procedure can be performed through several access routes, most commonly via the transfemoral approach (utilised in more than 90% of patients at most centres),4 which is possible when the patient has suitable iliofemoral anatomy and does not suffer from other vessel disease.5
Iterative improvements in TAVI valve and delivery systems have contributed to the increased suitability of patients for transfemoral TAVI and the increased numbers of TAVI procedures.3 For example in the Edwards PARTNER trials, suitability for transfemoral TAVI has increased from 70% with the Edwards SAPIEN valve6 to 76% and 88% with the Edwards SAPIEN XT 7and SAPIEN 3 valves8 respectively.
*The 23 mm and 26 mm Edwards SAPIEN 3 are compatible with the 14F eSheath set. The 16F eSheath set is required for the 29 mm Edwards SAPIEN 3 valve. Edwards SAPIEN, Edwards SAPIEN XT, Edwards SAPIEN 3 and eSheath are trademarks of Edwards Lifesciences Corporation or its affiliates. Dates refer to CE Mark approval.
See below for an overview of the transfemoral approach for TAVI using balloon-expandable technology.
TAVI may be advantageous compared with surgery
TAVI provides short- and long-term symptom relief, as well as improved life expectancy and quality of life. Compared with open heart surgery, TAVI may offer the following benefits:
- is less invasive9
- is a shorter procedure10
- reduces patient time in intensive care7
- offers shortened recovery time11
- leads to less pain and a shorter hospital stay12, 13
- offers a more rapid improvement in quality of life13
TAVI has a low risk of major adverse cerebrovascular and cardiac events.14 Furthermore, stable valve durability has been demonstrated up to 5 years of follow-up.6, 15