Advertisement

Transcatheter Aortic Valve Replacement: Management of High-Risk Patients and Complex Procedures

  • Brandon M. Jones
  • Lars G. Svensson
  • Samir R. KapadiaEmail author
Chapter

Abstract

Aortic stenosis (AS) is an increasingly common problem in developed countries. While surgical aortic valve replacement (SAVR) has long been the gold standard for managing severe, symptomatic AS, there has been a significant shift in the age and complexity of patients requiring intervention, and as a result, an increasing number of patients are not candidates for surgery. Transcatheter aortic valve replacement (TAVR) has developed into a vital alternative for inoperable patients and has shown excellent results in high- and even moderate-risk populations. As the technology has evolved over more than a decade since the first in-human TAVR, the procedure itself has become in many ways routine, has shown excellent safety, and has been adopted by hundreds of hospitals throughout the world. Despite this rapid expansion of TAVR technology, the patient population remains very complex, and individuals frequently have significant comorbid conditions that make TAVR anything but routine. Therefore, the goal of this chapter is to discuss the management of especially high-risk or atypical patients requiring TAVR, how to approach uncommon anatomy or comorbid conditions, and the management of unusual procedural complications.

Keywords

Transcatheter aortic valve replacement Subclavian access Transseptal Transcaval Transcarotid Small aortic root 

References

  1. 1.
    Iung B, Cachier A, Baron G, Messika-Zeitoun D, Delahaye F, Tornos P, et al. Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur Heart J. 2005;26:2714–20.CrossRefGoogle Scholar
  2. 2.
    Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597–607.CrossRefGoogle Scholar
  3. 3.
    Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–98.CrossRefGoogle Scholar
  4. 4.
    Popma JJ, Adams DH, Reardon MJ, Yakubov SJ, Kleiman NS, Heimansohn D, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014;63:1972–81.CrossRefGoogle Scholar
  5. 5.
    Adams DH, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. 2014;370:1790–8.CrossRefGoogle Scholar
  6. 6.
    Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609–20.CrossRefGoogle Scholar
  7. 7.
    Thourani VH, Kodali S, Makkar RR, Herrmann HC, Williams M, Babaliaros V, et al. Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet. 2016;387:2218–25.CrossRefGoogle Scholar
  8. 8.
    Cohen MG, Singh V, Martinez CA, O’Neill BP, Alfonso CE, Martinezclark PO, Heldman AW, O’Neill WW. Transseptal antegrade transcatheter aortic valve replacement for patients with no other access approach - a contemporary experience. Catheter Cardiovasc Interv. 2013;82:987–93.CrossRefGoogle Scholar
  9. 9.
    Greenbaum AB, O’Neill WW, Paone G, Guerrero ME, Wyman JF, Cooper RL, Lederman RJ. Caval-aortic access to allow transcatheter aortic valve replacement in otherwise ineligible patients: initial human experience. J Am Coll Cardiol. 2014;63:2795–804.CrossRefGoogle Scholar
  10. 10.
    Mylotte D, Sudre A, Teiger E, Obadia JF, Lee M, Spence M, et al. Transcarotid transcatheter aortic valve replacement: feasibility and safety. JACC Cardiovasc Interv. 2016;9:472–80.CrossRefGoogle Scholar
  11. 11.
    Campelo-Parada F, Rodes-Cabau J, Dumont E, Del Trigo M, Regueiro A, Doyle D, et al. A novel transcarotid approach for implantation of balloon-expandable or self-expandable transcatheter aortic valves. Can J Cardiol. 2016;32:1575.CrossRefGoogle Scholar
  12. 12.
    Pasic M, Unbehaun A, Buz S, Drews T, Hetzer R. Annular rupture during transcatheter aortic valve replacement: classification, pathophysiology, diagnostics, treatment approaches, and prevention. JACC Cardiovasc Interv. 2015;8:1–9.CrossRefGoogle Scholar
  13. 13.
    Khatri PJ, Webb JG, Rodes-Cabau J, Fremes SE, Ruel M, Lau K, Guo H, Wijeysundera HC, Ko DT. Adverse effects associated with transcatheter aortic valve implantation: a meta-analysis of contemporary studies. Ann Intern Med. 2013;158:35–46.CrossRefGoogle Scholar
  14. 14.
    Athappan G, Patvardhan E, Tuzcu EM, Svensson LG, Lemos PA, Fraccaro C, et al. Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature. J Am Coll Cardiol. 2013;61:1585–95.CrossRefGoogle Scholar
  15. 15.
    Tamburino C, Capodanno D, Ramondo A, Petronio AS, Ettori F, Santoro G, et al. Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis. Circulation. 2011;123:299–308.CrossRefGoogle Scholar
  16. 16.
    Jones BM, Tuzcu EM, Krishnaswamy A, Popovic Z, Mick S, Roselli EE, et al. Prognostic significance of mild aortic regurgitation in predicting mortality after transcatheter aortic valve replacement. J Thorac Cardiovasc Surg. 2016;152:783–90.CrossRefGoogle Scholar
  17. 17.
    Okuyama K, Jilaihawi H, Kashif M, Soni V, Matsumoto T, Yeow WL, et al. Percutaneous paravalvular leak closure for balloon-expandable transcatheter aortic valve replacement: a comparison with surgical aortic valve replacement paravalvular leak closure. J Invasive Cardiol. 2015;27:284–90.PubMedGoogle Scholar
  18. 18.
    Dhoble A, Chakravarty T, Nakamura M, Abramowitz Y, Tank R, Mihara H, et al. Outcome of paravalvular leak repair after transcatheter aortic valve replacement with a balloon-expandable prosthesis. Catheter Cardiovasc Interv. 2016;89:462–8.CrossRefGoogle Scholar
  19. 19.
    Jones BM, Krishnaswamy A, Kapadia SR. Should embolic protection become the standard of care for stroke prevention during tavi? Rev Esp Cardiol (Engl Ed). 2016;69:890–3.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  • Brandon M. Jones
    • 1
  • Lars G. Svensson
    • 2
  • Samir R. Kapadia
    • 3
    Email author
  1. 1.Interventional CardiologyProvidence Valve CenterPortlandUSA
  2. 2.Sydell and Arnold Miller Family Heart and Vascular InstituteCleveland ClinicClevelandUSA
  3. 3.Sones Cardiac Catheterization Laboratory, Interventional Cardiology, Robert and Suzanne Tomsich Department of Cardiovascular MedicineCleveland ClinicClevelandUSA

Personalised recommendations