Ann Thorac Surg 2009;88:1474-1475. doi:10.1016/j.athoracsur.2009.09.010
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Todd M. Dewey, MD
Medical City Dallas Hospital, 7777 Forest Ln, Suite A323, Dallas, TX 75230
(Email: tdewey{at}csant.com).
Transcatheter aortic valve implantation (TAVI), either retrograde through a transfemoral approach or antegrade through a transapical approach, has become a clinical reality in the treatment of critical aortic stenosis in high-risk patients. The commercialization of both self-expanding and balloon expandable platforms in Europe, together with their escalating use, has the potential for intrinsically altering the way we think of the treatment for aortic stenosis. Despite the early enthusiasm for this technology, a number of critical questions remain unanswered, such as:
- 1 What is the appropriate patient population for its use?
- 2 What are the long term effects of mild to moderate paravalvular leak?
- 3 Who should be the "gate-keepers" for this technology?
Thielmann and colleagues [1] describe the procedural and intermediate term outcomes of a subset of patients at the extremes of risk within a larger group of high-risk patients receiving transcatheter therapy. By examining patients with an average logistic EuroSCORE of 44.2 ± 12.6% and a mean Society of Thoracic Surgeons' predicted risk of mortality of 17.9 ± 6.1%, the authors demonstrate the efficacy of transcatheter therapy in the "worst of the worst" with aortic stenosis. Acceptable 30-day, 6-month, and 12-month survival is established, along with excellent early and late prosthetic hemodynamic performance, as demonstrated by low transvalvular gradients and large effective orifice areas. Paravalvular leak was noted in nearly 50% of patients early after the procedure, and remained relatively unchanged on follow-up. The authors also corroborate other reports regarding the superiority of The Society of Thoracic Surgeons' risk algorithm in comparison with the logistic EuroSCORE in predicting mortality of a high-risk population [2].
As capably demonstrated in this article, transcatheter technology can be a "game changer" in a population of patients with limited options. However, these patients remain a minority in the overall population of patients with aortic stenosis, and the temptation to expand the scope of this technology into younger and healthier patients must be tempered by data. Future trials investigating TAVI in groups previously treated with conventional aortic valve replacement are in the planning stages, and these trials will be crucial to justify its use in these patients. This is particularly true given the implications regarding patient access to this technology, and the specter of competition between current stakeholders to control its use. The TAVI train seems to be leaving the station, and the best option for surgeons to have meaningful impact on its development and ultimate use is to get on for the ride.
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References
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- Thielmann M, Wendt D, Eggebrecht H, et al. Transcatheter aortic valve implantation in patients with very high risk for conventional aortic valve replacement Ann Thorac Surg 2009;88:1468-1475.[Abstract/Free Full Text]
- Dewey TM, Brown D, Ryan WH, et al. Reliability of risk algorithms in predicting early and late operative outcomes in high-risk patients undergoing aortic valve replacement J Thorac Cardiovasc Surg 2008;135:180-187.[Abstract/Free Full Text]
Related Article
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Transcatheter Aortic Valve Implantation in Patients With Very High Risk for Conventional Aortic Valve Replacement
- Matthias Thielmann, Daniel Wendt, Holger Eggebrecht, Philipp Kahlert, Parwis Massoudy, Markus Kamler, Raimund Erbel, Heinz Jakob, and Stefan Sack
Ann. Thorac. Surg. 2009 88: 1468-1474.
[Abstract]
[Full Text]
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