Considerations for TAVI or SAVR in Patients With Aortic Stenosis

Windecker S, Okuno T, Unbehaun A, Mac M, Kapadia S, Falk V.
Which Patients With Aortic Stenosis Should Be Referred to Surgery Rather Than Transcatheter Aortic Valve Implantation? Eur Heart J 2022;Apr 25:[Epub ahead of print].

The following are key points to remember from this state-of-the-art review on considerations for aortic valve replacement therapy:

  1. Transcatheter aortic valve implantation (TAVI) has matured into an accepted mainstay treatment option for patients with severe symptomatic aortic valve stenosis (AS) across the whole spectrum of risk.
  2. The advances in the interventional treatment of AS has raised the question of which patients with severe AS should still be referred to surgery.
  3. The myriad of clinical permutations does not allow providing a single, uniform treatment strategy for all patients.
  4. Rather, the advent of TAVI along with established surgical aortic valve replacement (SAVR) fundamentally enforces the role of the multidisciplinary heart team for decision-making recommendations.
  5. Involvement of the informed patient expressing treatment preferences is crucial for a shared decision-making process.
  6. In general, SAVR is preferred in patients with excessive calcification in the device implantation zone, as the calcified leaflets can be safely resected and any calcium extension into the annulus and left ventricular outflow tract can be completely debrided.
  7. Furthermore, the risk of new conduction disturbances is an important consideration for treatment selection in patients at high risk for conduction disturbances, and SAVR emerges as the preferred option, particularly in young patients with long life expectancy.
  8. TAVI with contemporary devices appears to be safe and effective for elderly patients with bicuspid AS; however, SAVR should remain the primary treatment option for bicuspid AS in young patients and independent of age when the bicuspid aortic valve morphology is unfavorable or significant aortopathy coexists.
  9. Valve durability data are at this time not conclusive for the decision-making between TAVI and SAVR, but need to be considered for the decision-making between bioprostheses and mechanical prostheses (or the Ross procedure) in younger patients ≤65 years of age.
  10. Finally, anatomical and clinical factors, remaining uncertainties related to TAVI and SAVR, and lifetime management strategies now take center stage in the decision-making process and the multidisciplinary heart team plays a decisive role to provide an optimal treatment recommendation in a shared decision-making process for individual patients and to define the lifetime sequence of interventions.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Quality Improvement, Interventions and Structural Heart Disease

Keywords: Aortic Valve Stenosis, Bicuspid Aortic Valve Disease, Bioprosthesis, Cardiac Surgical Procedures, Heart Defects, Congenital, Heart Valve Diseases, Heart Valve Prosthesis, Heart Valve Prosthesis Implantation, Secondary Prevention, Treatment Outcome

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