Should patients with low-moderate surgical risk be offered TAVI instead of conventional aortic valve replacement in the management of symptomatic aortic stenosis?

  • Charles Malcolm Rees University of Liverpool
  • Eric HO university of liverpool
Keywords: Cardiology, cardiothoracic, tavi, aortic stenosis, heart surgery, aortic valve replacement, avr, transcatheter aortic valve implantation

Abstract


Introduction: Surgical aortic valve replacement (AVR) is the current gold standard treatment for symptomatic aortic stenosis. Without surgical intervention, patients experience a period of rapid clinical worsening, with 50% mortality within two years. However AVR in itself carries considerable risk and many patients may be considered too high risk and therefore not candidates for surgery. Transcatheter Aortic Valve implantation (TAVI) was conceived in 2002 which showed comparable results to AVR in patient are at high surgical risk. TAVI is indicated for high risk patients and in patients that are contraindicated to surgery. Due to increasing public interest there is demand for TAVI to
be used within lower risk patients. This is currently being assessed through the large SURTAVI and PARTNER A trials.


Aim: The aim of this review is to appraise the current indications surrounding the use of TAVI in potentially low-moderate surgical risk patients and inform its readers about the history of TAVI and its future direction. This paper also addresses the pathogenesis, epidemiology, management and prognosis of aortic stenosis from the most up
to date research studies. 

Methods: A systematic review was conducted. Databases searched included MEDLINE, Embase, AMED, Science Direct, UPTODATE and the British Journal of Cardiology for papers published from the period of January 1990-present. Combinations of the following terms were used: ‘tavi, ‘transcatheter aortic valve implantation’, ‘aortic stenosis’, ‘treatment of aortic stenosis’, ‘aortic valve replacement’ ‘avr’ ‘Medtronic core valve’ ‘bioprosthetic heart
valves’, ‘edward sapien bioprostheis’ and ‘treatment of aortic stenosis’. All papers were from the most up to date sources and all information was cross referenced with NICE guidelines and the UPTODATE database.


Results: 37 papers were selected for review. The main findings included: the incidence of aortic stenosis is rising due to advances in medical treatment resulting in an aging population; AVR is the current gold standard treatment for aortic stenosis; TAVI is superior to medical therapy alone; TAVI is indicated in high surgical risk patients and those that are contraindicated to surgery; TAVI is comparable to AVR in high risk patients; studies have shown comparable result comparing TAVI with AVR in low- moderate risk pateints; the wide SURTAVI and PARTNER A trials are currently assessing the use of TAVI in low-moderate risk patients.


Conclusions: TAVI has revolutionized an alternative way of thinking towards the management of symptomatic aortic stenosis. TAVI is indicated in patient whom are at high surgical risk and in cases where surgery is contraindicated. AVR remains the gold standard treatment in low-moderate surgical risk patients. TAVI may be considered as an alternative method to surgical AVR following the results of the PARTNER 2 and SURTAVI trials.

Author Information

Charles Malcolm Rees, University of Liverpool
Final year medical student
Eric HO, university of liverpool
Final year medical student

References

1) Faggiano P, Antonini-Canterin F, Erlicher A, Romeo C, Cervesato E, Pavan D, Piazza R, et al. Progression of aortic valve sclerosis to aortic stenosis. Am J Cardiol. 2003 Jan 1;91(1):99-101. PMID:12505585.
2) Faggiano P, Antonini-Canterin F, Baldessin F, Lorusso R, D'Aloia A, Cas LD. Epidemiology and cardiovascular risk factors of aortic stenosis. Cardiovasc Ultrasound. 2006 Jul 1;4:27. PMID:16813661.
3) Nishimura. RA, Otto CM, Bownow RO et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg. 2014;148(1):e1-e132. PMID:24939033.
4) Otto CM, Bonow RO. Valvular heart disease. In: Bonow RO, Mann DL, Zipes Dp, Libby P, Braunwald E, eds.Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. St. Louis, MO: WB Saunders; 2011:chap 66.
5) Rajamannan NM, Evans FJ, Aikawa E, Grande-Allen KJ, Demer LL, Heistad DD, et al. Calcific aortic valve disease: not simply a degenerative process: A review and agenda for research from the national Heart and Lung and Blood institute Aortic Stenosis Working group. Calcific aortic valve disease-2011 update. Circulation. 2011 Oct 18;124(16):1783-91. PMID:2200710.
6) Hinton RB, Yutzey KE. Heart valve structure and function in development and disease. Annu Rev Physiol. 2011;73:29-46. PMID: 20809794
7) Akat K, Borggrefe M, Kaden JJ. Aortic valve calcification: basic science to clinical practice. Heart. 2009;95(8):616-623. PMID:18632833.
8) Carabello BA, Paulus WJ. Aortic stenosis. Lancet. 2009;373(9667):956-966. PMID:19232707.
9) Otto CM, Bonow RO. Valvular Heart Disease: A Companion to Braunwald’sHeart Disease. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2009.
10) Milani RV, Drazner MH, Lavie CJ, Morin DP, Ventura HO. Progression from concentric left ventricular hypertrophy and normal ejection fraction to left ventricular dysfunction. Am J Cardiol. 2011 Oct 1;108(7):992-6. PMID:21784383.
11) Katholi RE, Couri DM. Left ventricular hypertrophy: major risk factor in patients with hypertension: update and practical clinical applications. Int J Hypertens. 2011;2011:495349. PMID:21755036.
12) Dragu R, Rispler S, Habib M, Sholy H, Hammerman H, Galie N, Aronson D. Pulmonary arterial capacitance in patients with heart failure and reactive pulmonary hypertension. Eur J Heart Fail. 2014 Nov 11. PMID:25388783.
13) Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, et al. Natural history of very severe aortic stenosis. Circulation. 2010 Jan 5;121(1):151-6. PMID:20026771.
14) Ruel M, Kapila V, Price J, Kulik A, Burwash IG, Mesana TG.Natural history and predictors of outcome in patients with concomitant functional mitral regurgitation at the time of aortic valve replacement. Circulation 2006;114:I-541-6. PMID:16820634.
15) Dweck MR, Boon NA, Newby DE. Calcific aortic stenosis: a disease of the valve and the myocardium. J Am Coll Cardiol. 2012 Nov 6;60(19):1854-63. PMID:23062541.
16) Peter M, Hoffmann A, Parker C, Lüscher T, Burckhardt D. Progression of aortic stenosis. Role of age and concomitant coronary artery disease. Chest. 1993 Jun;103(6):1715-9. PMID:8404089.
17) Brown JM, O'Brien SM, Wu C, Sikora JA, Griffith BP, Gammie JS. Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks,valve types, and outcomes in the Society of Thoracic Surgeons National Database. J Thorac Cardiovasc Surg. 2009 Jan;137(1):82-90. PMID:19154908.
18) Kojodjojo P, Gohil N, Barker D, Youssefi P, Salukhe TV, Choong A, et al. Outcomes of elderly patients aged 80 and over with symptomatic, severe aortic stenosis: impact of patient'schoice of refusing aortic valve replacement on survival. QJM. 2008 Jul;101(7):567-73. PMID:18443003.
19) Cribier A, Eltchaninoff H, Bash A, Borenstein N, Tron C, Bauer F, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation. 2002 Dec 10;106(24):3006-8. PMID:12473543.
20) Hutchinson N. Sedation vs general anaesthesia for the 'high-risk' patient--what can TAVI teach us? Anaesthesia. 2011 Nov;66(11):965-8. PMID:21933158.
21) 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 Oct 21;363(17):1597-607. PMID:20961243.
22) Kahlert P, Knipp SC, Schlamann M, Thielmann M, Al-Rashid F, Weber M, et al. Silent and apparent cerebral ischemia after percutaneous transfemoral aortic valve implantation: a diffusion-weighted magnetic resonance imaging study. Circulation 2010;121:870-878. PMID: 20177005.
23) Ghanem A, Müller A, Nähle CP, Kocurek J, Werner N, Hammerstingl C, et al. Risk and fate of cerebral embolism after transfemoral aortic valve implantation: a prospective pilot study with diffusion-weighted magnetic resonance imaging. J Am Coll Cardiol 2010;55:1427-1432. PMID:20188503.
24) 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 Jun 9;364(23):2187-98. PMID:21639811.
25) 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 May 8;370(19):1790-8. PMID:24678937.
26) Kodali SK, Williams MR, Smith CR, Svensson LG, Webb JG, Makkar RR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med. 2012 May 3;366(18):1686-95. PMID:22443479.
27) Ussia GP, Scarabelli M, Mulè M, Barbanti M, Sarkar K, Cammalleri V, et al. Dual antiplatelet therapy versus aspirin alone in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2011 Dec 15;108(12):1772-6. PMID:21907949.
28) https://www.nice.org.uk/guidance/ipg421
29) Thomas M, Schymik G, Walther T, Himbert D, Lefèvre T, Treede H, et al. Thirty-day results of the SAPIEN aortic Bioprosthesis European Outcome (SOURCE) Registry: A Europeanregistry of transcatheter aortic valve implantation using the Edwards SAPIEN valve. Circulation. 2010 Jul 6;122(1):62-9. PMID:20566953.
30) Gilard M, Eltchaninoff H, Iung B, Donzeau-Gouge P, Chevreul K, Fajadet J, et al. Registry of transcatheter aortic-valve implantation in high-risk patients. N Engl J Med. 2012 May 3;366(18):1705-15. PMID:22551129.
31) Blackman DJ, Baxter PD, Gale CP, Moat NE, Maccarthy PA, Hildick-Smith D, et al. Do outcomes from transcatheter aortic valve implantation vary according to access route and valve type? The UK TAVI Registry. J Interv Cardiol. 2014 Feb;27(1):86-95. PMID:24373048.
32) Kovac J, Baron JH, Chin DT. Are the standard criteria for TAVI too lax or too strict? Heart. 2010 Jan;96(1):5-6. PMID:19778924.
33) Gurvitch R, Wood DA, Tay EL, Leipsic J, Ye J, Lichtenstein SV, et al. Transcatheter aortic valve implantation: durability of clinical and hemodynamic outcomes beyond 3 years in a large patient cohort. Circulation. 2010 Sep 28;122(13):1319-27. PMID:20837893.
34) Daneault B, Kirtane AJ, Kodali SK, Williams MR, Genereux P, Reiss GR, et al. Stroke associated with surgical and transcatheter treatment of aortic stenosis: a comprehensive review. J Am Coll Cardiol. 2011 Nov 15;58(21):2143-50. PMID:22078419.
35) Hayashida K, Lefèvre T, Chevalier B, Hovasse T, Romano M, Garot P, et al. Transfemoral aortic valve implantation new criteria to predict vascular complications. JACC Cardiovasc Interv. 2011 Aug;4(8):851-8. PMID:21851897.
36) Piazza N, Nuis RJ, Tzikas A, Otten A, Onuma Y, García-García H, et al. Persistent conduction abnormalities and requirements for pacemaking six months after transcatheter aorticvalve implantation. EuroIntervention. 2010 Sep;6(4):475-84. PMID:20884435.
37) Amat-Santos IJ, Rodés-Cabau J, Urena M, DeLarochellière R, Doyle D, Bagur R, et al. Incidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aorticvalve implantation. J Am Coll Cardiol. 2012 Jan 10;59(2):178-88. PMID:22177537.
Published
21-Dec-2015
How to Cite
Rees, C., & HO, E. (2015, December 21). Should patients with low-moderate surgical risk be offered TAVI instead of conventional aortic valve replacement in the management of symptomatic aortic stenosis?. Res Medica, 23(1), 15-21. https://doi.org/https://doi.org/10.2218/resmedica.v23i1.1233
Section
Clinical Review Article