Advancements and Challenges in Transcatheter Aortic Valve Replacement (TAVR)

Surgical aortic valve replacement (SAVR) was the only symptom relieving and life-prolonging treatment until transcatheter aortic valve implantation (TAVI) became available. This option was introduced to treat old and high-risk patients. In a series of 2500 consecutive patients referred for SAVR with a biologic heart valve (BHV) prosthesis, their age, comorbid conditions, the complexity of the procedure, postoperative outcome, need for resources, and long-term survival were compared in patients before versus after the introduction of TAVI. Although the Carpentier-Edwards valve was used in most patients, the outcomes with respect to several other BHV types were studied. Patients undergoing isolated SAVR (i-SAVR) were studied separately from those who underwent SAVR with a concomitant procedure (c-SAVR). The number of referrals increased over time until 2016, whereafter the reimbursement for TAVI broadened. Age, prior percutaneous coronary interventions, diabetes, and chronic renal disease increased over time in both groups, while atrial fibrillation, the need for emergent SAVR, and other comorbid conditions increased significantly only in the c-SAVR group. Postoperative acute renal injury, conduction defects, and bleeding increased over time in both groups. The need for renal replacement therapy increased in both surgical groups, but this was more pronounced in c-SAVR; the need for a pacemaker implant (p < 0.001), blood products, and reintervention increased only in the c-SAVR group. There was a moderate but non-significant increase in the 30-day mortality for both groups over time. Furthermore, the long-term survival of both groups did not change after the introduction of TAVI. The Carpentier-Edwards Perimount valve showed good long-term results for durability. The Perceval device was used in older patients and showed good hemodynamic results, but the need for a postoperative permanent pacemaker implant was high. The results seem to indicate that a broader reimbursement for TAVI was warranted after its introduction in 2008. Nevertheless, with the development of newer devices for SAVR, surgery will remain one of the major treatment options for aortic valve disease. Full article

Prosthetic valve endocarditis (PVE) has undergone significant changes over the past five decades and is currently affecting an aging population, with an increasing prevalence in patients with transcatheter valve implants. The introduction of transcatheter aortic valve replacement (TAVR) represents a significant advance in the field of interventional cardiology and cardiac surgery. The incidence of IE after TAVR has remained stable, with rates similar to those reported after surgical aortic valve replacement. This is despite significant refinements in the TAVR procedure, with less invasive handling and its extension to younger and healthier patients. TAVR should be considered as a potential treatment option for patients with PVE, despite some differences. In terms of evolutionary advances, there have been notable and significant developments in the fields of microbiology and imaging diagnostics. The 2023 Duke-International Society for Cardiovascular Infectious Diseases diagnostic criteria for infective endocarditis now incorporate significant advances in molecular biology and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography. This has led to a significant enhancement in diagnostic sensitivity for PVE while maintaining the same level of specificity in validation studies. PVE is a deadly disease. A multidisciplinary endocarditis treatment team in a cardiac center is essential to improve outcomes. The availability of novel surgical options allows clinicians to offer an increasing number of patients the opportunity to avoid surgical intervention. Some patients will complete antimicrobial treatment at home. Those with prosthetic valves are eligible for antibiotic prophylaxis before dental procedures. Post-TAVR infective endocarditis (IE) is a subcategory of prosthetic valve endocarditis. This condition presents a particularly complex scenario, characterized by a distinctive clinical and microbiological profile, a high prevalence of IE-related complications, an ambiguous role of cardiac surgery, and a poor prognosis for the majority of patients with TAVR IE. The number of TAVR procedures is set to skyrocket in the coming years, which will undoubtedly lead to a significant rise in the number of people at risk of this life-threatening complication. This review will provide an overview of this rare complication in light of the advent of IE following TAVR. It is crucial to gain a comprehensive understanding of the disease and its associated complications to enhance clinical outcomes. Full article