Future Expectations and Barriers for TAVR

Vahl TP, Kodali SK, Leon MB.
Transcatheter Aortic Valve Replacement (TAVR) 2016: A Modern-Day “Through the Looking-Glass” Adventure. J Am Coll Cardiol 2016;67:1472-1487.

The following are key points to remember about transcatheter aortic valve replacement (TAVR) currently, as well as future expectations and barriers:

  1. Transcatheter aortic valve replacement (TAVR) has become a safe and effective therapy for selected patients with severe aortic stenosis (AS).
  2. In recent trials, the hemodynamic performance and clinical outcomes of the latest generation of TAVR devices demonstrated at least parity with surgical outcomes in patients of similar risk.
  3. On the basis of current clinical evidence, TAVR has been accepted by the American Heart Association (AHA)/American College of Cardiology (ACC) guidelines as a Class I indication in patients with severe symptomatic AS and a predicted survival of more than 1 year, who are not candidates for SAVR.
  4. The current guidelines also recommend that TAVR, as a Class IIa indication, should be an alternative to conventional surgery in severely symptomatic AS patients who are at high risk for mortality and complications after SAVR.
  5. Many initial obstacles with TAVR have been largely overcome, including frequent access site complications and concerns about strokes and paravalvular leaks.
  6. Using a multidisciplinary heart team approach, patient selection, procedural planning, and device implantation have been refined and optimized such that clinical outcomes are generally predictable and reproducible. The routine use of a heart valve team (in essentially every case) is now the guideline-recommended approach for TAVR and is a Class I indication in both the ACC/AHA and European Society of Cardiology guidelines.
  7. In the current era of TAVR systems, valve positioning accuracy has improved dramatically due to both design enhancements, which have improved valve stability during deployment, and the availability of retrievable and repositionable delivery systems with newer versions of self-expanding TAVR devices.
  8. Future research will focus on the durability of TAVR devices, further enhancements in clinical outcomes, and adjunctive therapies. Predictions for future TAVR systems include even lower-profile devices (ensuring percutaneous transfemoral access for almost all patients), further refinements of design attributes, and novel technologies, such as tissue-engineered heart valves.
  9. On the basis of initial results from ongoing clinical trials, it appears that the indication for TAVR may expand to lower-risk patients in the future.
  10. Overall, the modern-day medical adventure of TAVR has transformed clinical practice and will remain an important contribution in the management of patients with AS.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Hemodynamics, Heart Valves, Heart Valve Diseases, Risk, Stroke, Transcatheter Aortic Valve Replacement

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