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Transcatheter Aortic Valve Replacement: Challenges and Future Directions

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiovascular Medicine".

Deadline for manuscript submissions: closed (25 November 2024) | Viewed by 13080

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Dr. Walid Ben-Ali

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Department of Cardiac Surgery, Montreal Heart Institute, Montreal University, Montreal, QC H1T 1C8, Canada
Interests: structural valve procedures; artificial intelligence; simulation
Special Issues, Collections and Topics in MDPI journals

Dr. Anita W. Asgar

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Interventional Cardiology Department, Montreal Heart Institute, Montreal University, Montreal, QC H1T 1C8, Canada
Interests: structural valve procedures; artificial intelligence; simulation

Dr. Thomas E. Modine

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Unité Médico-Chirugical, CHU de Bordeaux, University of Bordeaux, Bordeaux, France
Interests: structural valve procedures; artificial intelligence; simulation

Special Issue Information

Dear Colleagues,

TAVI is now the favoured treatment option for a large number of patients who present with symptomatic severe aortic stenosis (with more than one million implants worldwide). Indeed, recent intermediate and low-risk trials had confirmed the non-inferiority and even the superiority of TAVI over surgical aortic valve replacement (SAVR) for some outcomes, such as early safety benefits, faster discharge from hospital, fewer rehospitalizations, and durability. Do these trials herald the end of isolated SAVR? Despite these very encouraging findings from these trials, about one third of patients in PARTNER 3 trial and 15% of the patients in the Evolut Low-Risk Trial failed the screening process. Therefore, the generalizability of these results is not as obvious as we are led to believe. In this Special Issue, we will consider limitations of the transition to TAVI in younger patients, as well as discuss challenges associated with expanding TAVI indications in bicuspid aortic valves, aortic regurgitation, small annuli, VIV, and TAV in TAV procedures, by highlighting ongoing trials and identifying areas of unmet needs in which continued refinements are required for optimizing cerebral embolic protection, using artificial intelligence plans, and guiding and predicting TAVR procedure results.

Dr. Walid Ben-Ali
Dr. Anita W. Asgar
Dr. Thomas E. Modine
Guest Editors

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Keywords

transcatheter aortic valve replacement
aortic valve
TAVR
challenges
future directions

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Published Papers (9 papers)

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Research

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12 pages, 3817 KiB

Open AccessArticle

The Impact of Aortic Arch Morphology on Periprocedural Stroke in Transcatheter Aortic Valve Replacement

by Stephanie Voss, Katerina Rusa, Caterina Campanella, Teodora Georgescu, Keti Vitanova, Hendrik Ruge, Andrea Amabile, Konstantinos Sideris, Markus Krane and Melchior Burri

J. Clin. Med. 2025, 14(4), 1045; https://doi.org/10.3390/jcm14041045 - 7 Feb 2025

Viewed by 812

Abstract

Objectives: Stroke after transcatheter aortic valve replacement (TAVR) continues to be one of the most concerning complications. Anatomical variations of the aortic arch may increase the risk of embolic debris entering the brain during transfemoral catheter manipulation. We aimed to analyze the influence of aortic arch morphology on the occurrence of ischemic stroke during TAVR. Methods: We performed a retrospective, 1:2 propensity-matched case–control study to compare patients with and without periprocedural stroke (defined according to the Valve Academic Research Consortium III endpoints) after transfemoral TAVR between June 2007 and September 2022. Multi-slice computed tomography (MSCT) analysis of pre-TAVR aortograms was performed to investigate arch anatomy, configuration, curvature, and the take-off angles of the epi-aortic vessels. Results: A total of 2371 patients were enrolled in this study. Periprocedural ischemic stroke was observed in 67 patients. After propensity score matching, this study included 201 patients: 67 (case) vs. 134 (control). The mean age was 80.0 ± 13.2 and 81.6 ± 6.4 years (p = 0.5), and the mean Euroscore II was 4.1 ± 3.6 and 4.3 ± 41 (p = 0.7). There was no difference in arch anatomy (p = 0.2) and configuration (p = 0.8) between the groups. Arch curvature (p = 0.9) and angulation of the brachiocephalic (p = 0.3) and left common carotid artery (p = 0.058) also did not differ significantly between the case and control groups. Conclusions: MSCT analysis in this propensity score-matched study found no correlation between aortic arch geometry and TAVR-associated stroke. Full article

(This article belongs to the Special Issue Transcatheter Aortic Valve Replacement: Challenges and Future Directions)

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15 pages, 2011 KiB

Open AccessArticle

Analysis of Calcium Patterns in the Thoracic Aorta and Clinical Outcomes of TAVR Patients Presenting with Porcelain Aorta

by Caterina Campanella, Stephanie Voss, Julia Schreyer, Nazan Puluca, Andrea Amabile, Felix Wirth, Markus Krane and Hendrik Ruge

J. Clin. Med. 2025, 14(2), 503; https://doi.org/10.3390/jcm14020503 - 14 Jan 2025

Viewed by 834

Abstract

Background/Objectives: In the presence of porcelain aorta (PA), transcatheter aortic valve replacement (TAVR) has become a class I therapeutic indication for the treatment of severe aortic valve stenosis. To date, few studies have analyzed the clinical outcomes of TAVR in PA patients. We aim to analyze the calcification patterns of the thoracic aorta in PA patients and to evaluate their clinical implications for TAVR procedures. Methods: This study included 161 patients who had PA confirmed through pre-operative CT and underwent TAVR between 11/2014 and 12/2022. The primary outcome was to perform a multi-slice CT (MSCT) analysis assessing the calcification in the proximal, middle, and distal thoracic aortic segments. Each segment was divided into quadrants for scoring calcifications on a scale from 1 (<25%) to 4 (>75%). The cohort was categorized into circular or noncircular calcification group. The secondary clinical outcomes were defined according to VARC-3 criteria. Results: The study cohort included 161 patients (median age, 77.2 years; IQR, 70.1–82.6 years). The median EuroSCORE II and STS predicted risk of mortality were 3.10% [1.80–5.58] and 2.70% [1.70–4.30], respectively. In 75% of patients (n = 121/161), TAVR was performed via transfemoral access. Circular calcifications were found in 8.1% of patients, while noncircular calcifications were present in 91.9%. Significant calcifications were primarily in the right quadrant of the proximal segment (33.54%), superior quadrant of the middle segment (39.75%), and left quadrant of the distal segment (73.29%). The 30-day mortality rate was 3.11% and periprocedural ischemic stroke rate 3.38%. Conclusions: Most TAVR patients with PA exhibited noncircular calcification. The most extensive calcifications were primarily in areas relevant to surgical manipulation. Patients with PA displayed low short-term mortality and relatively few stroke events. In view of these findings, TAVR constitutes a valid treatment option for patients with PA and aortic stenosis. Full article

(This article belongs to the Special Issue Transcatheter Aortic Valve Replacement: Challenges and Future Directions)

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13 pages, 910 KiB

Open AccessArticle

Prognosis and Predictor Factors of Permanent Pacemaker Implantation after Transcatheter Aortic Valve Replacement: A Retrospective Analysis of the Post-Transcatheter Aortic Replacement Clairval Hospital Registry

by Vassili Panagides, Emna Sakka, Edouard Cheneau, Ahmed Bouharaoua, Jacques Vicat, Elisabeth Leude-Vaillant, Philippe Rochas, Frédéric Collet and Marie-Paule Giacomoni

J. Clin. Med. 2024, 13(11), 3050; https://doi.org/10.3390/jcm13113050 - 22 May 2024

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Background/Objectives: Despite procedural improvements, post-transcatheter aortic valve replacement (TAVR) conduction disorders remain high. Analyzing the data from a monocentric TAVR registry, this study aims to determine predictive factors for PPI (primary outcome), the indication for PPI, and long-term outcomes among these patients (secondary outcomes). Methods: Conducted at Clairval Hospital in Marseille, France, this retrospective study included all consecutive patients from June 2012 to June 2019. Clinical, electrocardiographic, echocardiographic, and procedural data were collected, with outcomes assessed annually. Logistic regression identified PPI predictors and survival analyses were performed. Results: Of the 1458 patients initially considered, 1157 patients were included. PPI was needed in 21.5% of patients, primarily for third-degree atrioventricular block (46.4%). Predictor factors for PPI included baseline right bundle branch block (ORadj 2.49, 95% CI 1.44 to 4.30; p = 0.001), longer baseline QRS duration (ORadj 1.01, 95% CI 1.00 to1.02, p = 0.002), and self-expandable valves (ORadj 1.82, 95% CI, 1.09 to 3.03; p = 0.021). Seven-year estimated mortality was higher in PPI (43.3%) vs. non-PPI patients (30.9%) (log rank p = 0.048). PPI was an independent predictive factor of death (ORadj 2.49, 95% CI 1.4 to 4.3; p = 0.002). Conclusions: This study reveals elevated rates of PPI post-TAVR associated with increased mortality. These results underscore the pressing necessity to refine our practices, delineate precise indications, and enhance the long-term prognosis for implanted patients. Full article

(This article belongs to the Special Issue Transcatheter Aortic Valve Replacement: Challenges and Future Directions)

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11 pages, 3783 KiB

Open AccessArticle

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation in Patients with Severe Iliofemoral Calcifications: Expanding Transfemoral Indications

by Matthias Linder, David Grundmann, Caroline Kellner, Till Demal, Lara Waldschmidt, Oliver Bhadra, Sebastian Ludwig, Lisa Voigtländer, Ina von der Heide, Nicole Nebel, Laura Hannen, Johannes Schirmer, Hermann Reichenspurner, Stefan Blankenberg, Lenard Conradi, Niklas Schofer, Andreas Schäfer and Moritz Seiffert

J. Clin. Med. 2024, 13(5), 1480; https://doi.org/10.3390/jcm13051480 - 4 Mar 2024

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Abstract

(1) Background: Transfemoral transcatheter aortic valve implantation (TAVI) has become the standard treatment for most patients with severe symptomatic aortic stenosis. Intravascular lithotripsy may facilitate transfemoral TAVI (IVL-TAVI) even in patients with severely calcified iliofemoral disease. We assessed technical aspects and clinical outcomes of this novel approach compared to alternative transaxillary access (TAX-TAVI). (2) Methods: IVL-TAVI was performed for severe iliofemoral calcifications precluding standard transfemoral access in 30 patients from 2019 to 2022 at a single academic heart center. IVL was performed as part of the TAVI procedure in all cases. Results were compared to a control group of 44 TAX-TAVI procedures performed for the same indication from 2016 to 2021. The safety outcome was a composite of all-cause death, stroke, access-related bleeding ≥ type 2 within 24 h and major vascular access site complications at 30 days. The efficacy outcome was defined as a technical success according to VARC-3. (3) Results: Median age was 78.2 [74.3, 82.6] years, 45.9% were female and mean STS-PROM was 3.6% [2.3, 6.0]. Iliofemoral calcifications were more severe in the IVL-TAVI vs. TAX-TAVI groups (lesion length: 63.0 mm [48.6, 80.3] vs. 48.5 mm [33.1, 68.8]; p = 0.043, severe calcification at target lesion: 90.0% vs. 68.2%; p = 0.047, and median arc calcification 360.0° [297.5, 360.0] vs. 360.0° [180.0, 360.0]; p = 0.033). Technical success was achieved in 93.3% vs. 81.8% (p = 0.187) in IVL- and TAX-TAVI and the safety outcome occurred in 10.0% vs. 31.8% in IVL- and TAX-TAVI (p = 0.047), respectively. (4) Conclusions: IVL-assisted transfemoral TAVI was feasible and safe with favorable outcomes compared to TAX-TAVI. IVL may further expand the number of patients eligible for transfemoral TAVI and may help overcome limitations of an alternative access. Full article

(This article belongs to the Special Issue Transcatheter Aortic Valve Replacement: Challenges and Future Directions)

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10 pages, 1703 KiB

Open AccessArticle

Prognostic Implication of Intestinal Wall Edema in Patients with Aortic Stenosis Receiving Trans-Catheter Aortic Valve Replacement

by Kousuke Akao, Teruhiko Imamura, Shuhei Tanaka, Hiroshi Onoda, Ryuichi Ushijima, Mitsuo Sobajima, Nobuyuki Fukuda, Hiroshi Ueno and Koichiro Kinugawa

J. Clin. Med. 2023, 12(24), 7658; https://doi.org/10.3390/jcm12247658 - 13 Dec 2023

Cited by 1 | Viewed by 1199

Abstract

Background: A recently proposed mechanism, the intestinal–cardiovascular relationship, serves as a framework to elucidate the interplay between these two systems. In our investigation, we assessed the prognostic implications of colon wall thickness, a marker correlated with intestinal congestion and dysfunction, in patients diagnosed with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Methods: Patients diagnosed with severe aortic stenosis who underwent TAVR at our institution during the period spanning 2015 to 2022 were retrospectively enrolled. As part of the institutional protocol, patients underwent abdominal computed tomography upon admission, preceding TAVR. Our analysis aimed to assess the influence of colon wall thickness on the occurrence of either all-cause mortality or readmission due to heart failure within a two-year period. Results: A total of 345 patients were included. The median age was 85 (82, 88) years, and 99 patients were male. Baseline colon wall thickness was distributed widely, with a median value of 2.2 (2.0, 2.5) mm. Patients with thicker colon walls tended to have lower pulmonary artery pulsatility index values, indicating more impaired right ventricular function and more advanced malnutrition. A thicker colon wall was independently associated with 2-year death or heart failure readmission with a hazard ratio of 2.02 (95% confidence interval 1.01–14.07), adjusted for hemoglobin, age, and plasma B-type natriuretic peptide levels (p = 0.049), and significantly stratified the primary endpoint at a cutoff of 2.7 mm (25% versus 10%, p = 0.005). Conclusions: Our initial observation revealed that a thicker baseline colon wall correlated with increased rates of mid-term mortality and readmission due to heart failure subsequent to TAVR. Developing a comprehensive understanding of the underlying causality necessitates further in-depth investigations through subsequent studies. Full article

(This article belongs to the Special Issue Transcatheter Aortic Valve Replacement: Challenges and Future Directions)

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Review

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24 pages, 8005 KiB

Open AccessReview

What Are SAVR Indications in the TAVI Era?

by William Davalan, Walid Ben Ali, Sebastián Mrad and Pierre-Emmanuel Noly

J. Clin. Med. 2025, 14(7), 2357; https://doi.org/10.3390/jcm14072357 - 29 Mar 2025

Viewed by 1049

Abstract

While surgical aortic valve replacement (SAVR) has traditionally been regarded as the gold standard for severe symptomatic aortic stenosis (AS), transcatheter aortic valve implantation (TAVI) has emerged as a compelling less invasive alternative for patients with severe AS across the entire surgical risk spectrum. Despite TAVI’s increasing utilization and promising outcomes, SAVR continues to be an essential treatment modality for certain patient populations, including individuals with complex aortic anatomies unsuitable for TAVI, patients presenting with significant aortic regurgitation, individuals requiring concomitant surgical procedures, and cases involving infective endocarditis. Furthermore, concerns regarding the long-term durability and complication profile of transcatheter valves underscore the importance of individualized patient assessment, especially for younger patients requiring optimal lifetime management strategies. This review examines the evolving role of SAVR amidst the growing adoption of TAVI and highlights key considerations for selecting the most appropriate treatment strategy for patients with aortic valve disease, incorporating insights from recent advancements in transcatheter technologies and the latest clinical trial evidence. Full article

(This article belongs to the Special Issue Transcatheter Aortic Valve Replacement: Challenges and Future Directions)

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15 pages, 1632 KiB

Open AccessReview

Cerebral Embolic Protection Devices: Are There Any Indications in Transcatheter Aortic Valve Replacement?

by Neila Sayah, Ioannis Skalidis, Jules Mesnier, Antoinette Neylon, Mariama Akodad and Anita Asgar

J. Clin. Med. 2024, 13(18), 5471; https://doi.org/10.3390/jcm13185471 - 14 Sep 2024

Viewed by 1284

Abstract

Stroke following transcatheter aortic valve replacement (TAVR) is a significant and life-threatening adverse event. The vast majority of these incidents occur during the TAVR procedure or within the first 24 h following TAVR, with a notable prevalence of cerebral embolic events. In response to this concern, cerebral embolic protection devices (CEPDs) have been designed to mitigate the risk of peri-procedural ischemic stroke during TAVR. The primary objective of CEPDs is to diminish the intraprocedural burden associated with new silent ischemic brain injuries. Despite the development of several CEPDs, their clinical efficacy remains uncertain. In this review, we delve into a comprehensive analysis of the utilization of CEPDs in patients undergoing TAVR, exploring insights from the existing literature. Additionally, we aim to present future perspectives and discuss the clinical implications associated with the incorporation of CEPDs in TAVR procedures. Full article

(This article belongs to the Special Issue Transcatheter Aortic Valve Replacement: Challenges and Future Directions)

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16 pages, 6635 KiB

Open AccessReview

Aortic Valve-in-Valve Procedures: Challenges and Future Directions

by Davide Cao, Stefano Albani, Emmanuel Gall, Thomas Hovasse, Thierry Unterseeh, Patrick Seknadji, Stéphane Champagne, Philippe Garot, Neila Sayah and Mariama Akodad

J. Clin. Med. 2024, 13(16), 4723; https://doi.org/10.3390/jcm13164723 - 12 Aug 2024

Viewed by 2492

Abstract

Aortic valve-in-valve (ViV) procedures are increasingly performed for the treatment of surgical bioprosthetic valve failure in patients at intermediate to high surgical risk. Although ViV procedures offer indisputable benefits in terms of procedural time, in-hospital length of stay, and avoidance of surgical complications, they also present unique challenges. Growing awareness of the technical difficulties and potential threats associated with ViV procedures mandates careful preprocedural planning. This review article offers an overview of the current state-of-the-art ViV procedures, with focus on patient and device selection, procedural planning, potential complications, and long-term outcomes. Finally, it discusses current research efforts and future directions aimed at improving ViV procedural success and patient outcomes. Full article

(This article belongs to the Special Issue Transcatheter Aortic Valve Replacement: Challenges and Future Directions)

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15 pages, 1365 KiB

Open AccessReview

Alternative Access for TAVR: Choosing the Right Pathway

by Katherine Lutz, Karla M. Asturias, Jasmine Garg, Abhushan Poudyal, Gurion Lantz, Harsh Golwala, Julie Doberne, Amani Politano, Howard K. Song and Firas Zahr

J. Clin. Med. 2024, 13(12), 3386; https://doi.org/10.3390/jcm13123386 - 9 Jun 2024

Cited by 3 | Viewed by 1895

Abstract

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative treatment option for patients with severe aortic stenosis regardless of surgical risk, particularly in those with a high and prohibitive risk. Since the advent of TAVR, transfemoral access has been the standard of care. However, given comorbidities and anatomical limitations, a proportion of patients are not good candidates for a transfemoral approach. Alternative access, including transapical, transaortic, transaxillary, transsubclavian, transcarotid, and transcaval, can be considered. Each alternative access has advantages and disadvantages, so the vascular route should be tailored to the patient’s characteristics. However, there is no standardized algorithm when choosing the optimal alternative vascular access. In this review, we analyzed the evolution and current evidence for the most common alternative access for TAVR and proposed an algorithm for choosing the optimal vascular access in this patient population. Full article

(This article belongs to the Special Issue Transcatheter Aortic Valve Replacement: Challenges and Future Directions)

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