Immediate and Long-Term Echocardiographic Findings after Transcatheter Aortic Valve Implantation for the Treatment of Aortic Stenosis: The Cribier-Edwards/Edwards-Sapien Valve Experience

Minimally Invasive Sutureless Aortic Valve Replacement is Associated With Improved Outcomes in Patients With Left Ventricular Dysfunction

Objective

Patients with severe aortic stenosis and reduced left ventricular ejection fraction (LVEF) have a poor prognosis compared with patients with preserved LVEF. To evaluate the impact of sutureless Perceval (LivaNova, Italy) aortic bioprosthesis on LVEF and clinical outcomes in patients with baseline left ventricular (LV) dysfunction who underwent isolated aortic valve replacement (AVR).

Methods

Between March 2011 and August 2017, 803 patients underwent AVR with Perceval bioprosthesis implantation. Fifty-two isolated AVR had preoperative LVEF ≤45%. Mean age of these patients was 77 ± 6 years, 24 patients were female (46%), and mean EuroSCORE II was 9.4% ± 4.8%. Perceval bioprosthesis was implanted in 9 REDO operations. In 43 patients (83%), AVR was performed in minimally invasive surgery with an upper ministernotomy ( n = 13) or right anterior minithoracotomy ( n = 30).

Results

One patient died in hospital. Cardiopulmonary bypass and aortic cross-clamp times were 85.5 ± 26 minutes and 55.5 ± 19 minutes, respectively. At mean follow-up of 33 ± 20 months (range: 1 to 75 months), survival was 90%, freedom from reoperation was 100%, and mean transvalvular pressure gradient was 11 ± 5 mmHg. LVEF improved from 37% ± 7% preoperatively to 43% ± 8% at discharge ( P < 0.01) and further increased to 47% ± 9% at follow-up ( P = 0.06), LV mass decreased from 149.8 ± 16.9 g/m2 preoperatively to 115.3 ± 11.6 g/m2 at follow-up ( P < 0.001), and moderate paravalvular leakage occurred in 1 patient without hemolysis not requiring any treatment.

Conclusions

AVR with sutureless aortic bioprosthesis implantation in patients with preoperative LV dysfunction demonstrated a significant immediate and early improvement in LVEF.

Effect of aortic regurgitation following transcatheter aortic valve implantation on outcomes

The prognosis of aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) and the changes in AR grade over time remain unclear. This study evaluated the midterm survival associated with AR after TAVI and examined the evolution of AR over time and its effect on cardiac performance. Successful TAVI was performed in 314 patients (age 81 ± 7 years, 36% men). Serial transthoracic echocardiography and clinical assessment were available in 175 patients who survived >12 months. AR was assessed in terms of overall, paravalvular, and intravalvular severity. Significant post-TAVI AR (grade ≥2) was observed in 82 patients (26%), and these patients showed a trend toward reduced survival at 1- (93% vs 91%) and 2-year (89% vs 74%, log-rank p = 0.063) follow-up. Of the 175 patients who survived >12 months, grade ≥2 overall, paravalvular, and intravalvular AR were noted in 47 (27%), 32 (18%), and 8 patients (5%), respectively. Significant overall and paravalvular AR appeared to improve over time, particularly during the first 6 months (p <0.05), whereas intravalvular AR remained unchanged. Although improvements in the echocardiographic parameters were similar among patients with and without significant AR, patients who remained with grade ≥2 AR at 6 months had significantly worse survival than their counterparts at 2 years (80% vs 94%, log-rank p = 0.032). In conclusion, significant overall and paravalvular AR after TAVI appeared to improve over time. Although improvements in the echocardiographic parameters were similar, patients with grade ≥2 AR, both immediately after TAVI and at 6 months, were associated with worse survival.

Influence of aortic regurgitation after TAVI on left ventricular filling pattern

BACKGROUND

Paravalvular aortic regurgitation after transcatheter aortic valve implantation is associated with a hemodynamic deterioration and a poor outcome. We aim to determine the early hemodynamic effect of paravalvular aortic regurgitation in relation with the change in the left ventricle filling pattern and to assess their clinical outcome.

MATERIAL AND METHODS

Eighty-two consecutive patients referred for transcatheter aortic valve implantation were included. Patients were classified according to the change in the left ventricular filling pattern, and significant paravalvular aortic regurgitation (grade ≥ 2) was reported. Follow-up and incidence of death and hospitalization for heart failure were reported.

RESULTS

Sixteen patients (19·5%) presented a worsening of left ventricular filling pattern. The incidence of significant paravalvular aortic regurgitation was higher in the group with a worsening of left ventricular filling pattern (56·3% vs. 19·7%; P = 0·009). In the multivariate analysis, the only variable significantly associated with the worsening of left ventricular filling pattern was the significant paravalvular aortic regurgitation (OR 4·84; 95% CI 1·23 - 19·1; P = 0·024). During the follow-up (642·5 days), there was a higher incidence of the endpoint of death or hospitalization for heart failure in the group with a worsening of left ventricular filling pattern (62·5% vs. 31·8%; P = 0·042) and a lower event-free survival rate (long rank test = 0·013).

CONCLUSIONS

The presence of a significant paravalvular aortic regurgitation is associated with a worsening in parameters of diastolic function. This finding should alert the cardiologist as patients with a worsening of left ventricular filling pattern present a higher incidence of paravalvular aortic regurgitation and a less favourable outcome.

Access path angle in transapical aortic valve replacement: risk factor for paravalvular leakage

BACKGROUND

The aim of this study was to analyze the angle between the left ventricular (LV) long axis and the LV outflow tract (αLV-LVOT) on cardiac computed tomography and to describe its effect on the occurrence of paravalvular leakage (PL), fluoroscopy time, and postoperative creatine kinase-MB levels in transapical transcatheter aortic valve replacement (TA-TAVR).

METHODS

High-risk patients with severe aortic stenosis scheduled for TA-TAVR using an Edwards SAPIEN (Edwards Lifesciences, Irvine, CA) prosthesis were retrospectively included. The αLV-LVOT was measured during systole and diastole as far as retrospectively gated data sets were available. The αLV-LVOT was correlated with the occurrence of PL, total fluoroscopy time, and postoperative creatine kinase-MB levels. Interobserver variability was assessed in all cases.

RESULTS

The study included 81 patients (57 women [70.4%], 24 men [29.6%]) with an average age of 81.9±5.8 years. The mean αLV-LVOTs were 61.8±9.9 degrees during systole and 61.1±10.0 degrees during diastole. There was a minimal, nonsignificant change in the αLV-LVOT between systole and diastole of 0.2±4.1 degrees (p=0.7). PL was found in 39 patients: grade 0 in 42 (51.9%), grade I in 30 (37.0%), and grade II in 9 (11.1%). Patients with a clinically significant PL (grade≥II) showed a significantly greater mean αLV-LVOT than patients with grade I or without PL (mean difference, 13.8±3.2 degrees; p<0.001). No significant correlation was found between the αLV-LVOT and total fluoroscopy time (r=-0.17, p=0.16) and postoperative creatine kinase-MB levels (r=-0.1, p=0.44).

CONCLUSIONS

During TA-TAVR, greater αLV-LVOTs were associated with significantly higher grades of PL. Thus, the αLV-LVOT might influence the selection of the transapical implantation path and could have a significant effect on designs for future stents or novel delivery devices.

The current status of transcutaneous aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is a relatively novel procedure first performed in 2002 and has undergone rapid development since then. Its main indication is treatment of severe symptomatic aortic valve stenosis. Initially, the procedure was indicated for very sick patients who were not eligible for surgical aortic valve replacement. However, rapid development of the technology and operator skill required for TAVI allowed widening of the indications for its use. Currently, there is evidence that TAVI could be better than the surgical intervention in a broad population and not only in the most sick. This paper reviews the medical literature regarding TAVI, including the relevant medical equipment, different modes of its deployment, main complications of the procedure, main indications and contraindications, and the outcome of the patients who undergo it.

A critical review of hemodynamic changes and left ventricular remodeling after surgical aortic valve replacement and percutaneous aortic valve replacement

The introduction of transcatheter aortic valve replacement (TAVR) in clinical practice has widened options for symptomatic patients at high surgical risk; however, it is not known whether TAVR has equivalent or prolonged benefits in terms of left ventricular (LV) remodeling.

METHODS

To explore the relative hemodynamic benefits and postoperative LV remodeling associated with TAVR and surgical aortic valve replacement (SAVR), we performed a critical review of the available literature. A total of 67 studies were included in this systematic review.

RESULTS

There is at least equivalent if not slightly superior hemodynamic performance of TAVR over SAVR, and TAVR showed lower prosthesis-patient mismatch compared with SAVR. However, LV mass appears to regress to a greater degree after SAVR compared with TAVR. Aortic regurgitation, paravalvular in particular, is more common after TAVR than SAVR, although it is rarely more than moderate in severity. Improvements in diastolic function and mitral regurgitation are reported in only a handful of studies each and could not be compared across prosthesis types.

CONCLUSIONS

The published data support the hemodynamic comparability of SAVR and TAVR, with the higher incidence of prosthesis-patient mismatch in SAVR offset by higher incidence of paravalvular leak in TAVR. These results highlight the need for further studies focusing on hemodynamic changes after valve therapy.

Open issues in transcatheter aortic valve implantation. Part 1: patient selection and treatment strategy for transcatheter aortic valve implantation

An exponential increase in the use of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis has been witnessed over the recent years. The current article reviews different areas of uncertainty related to patient selection. The use and limitations of risk scores are addressed, followed by an extensive discussion on the value of three-dimensional imaging for prosthesis sizing and the assessment of complex valve anatomy such as degenerated bicuspid valves. The uncertainty about valvular stenosis severity in patients with a mismatch between the transvalvular gradient and the aortic valve area, and how integrated use of echocardiography and computed tomographic imaging may help, is also addressed. Finally, patients referred for TAVI may have concomitant mitral regurgitation and/or coronary artery disease and the management of these patients is discussed.

JenaValve

The JenaValve is a next-generation TAVI device which consists of a well-proven porcine root valve mounted on a low-profile nitinol stent. Feeler guided positioning and clip fixation on the diseased leaflets allow for anatomically correct implantation of the device without rapid pacing. Safety and efficacy of transapical aortic valve implantation using the JenaValve were evaluated in a multicentre prospective study that showed good short and midterm results. The valve was CE-mark released in Europe in September 2011. A post-market registry ensures on-going and prospective data collection in "real-world" patients. The transfemoral JenaValve delivery system will be evaluated in a first-in-man study in the near future.

Transcatheter aortic valve replacement in patients with severe aortic stenosis who are at high risk for surgical complications: summary assessment of the California Technology Assessment Forum

BACKGROUND

The California Technology Assessment Forum is dedicated to assessment and public reporting of syntheses of available data on medical technologies. In this assessment, transcatheter aortic valve replacement (TAVR) was evaluated for patients with severe aortic stenosis (AS) who are at high risk for complications.

METHODS AND RESULTS

In this assessment, 5 criteria were used: Regulatory approval, sufficient scientific evidence to allow conclusions on effectiveness, evidence that the technology improves net health outcomes, evidence that the technology is as beneficial as established methods, and availability of the technology outside investigational settings. In this assessment, all 5 criteria were judged to have been met. The primary benefit of TAVR is the ability to treat AS in patients who would otherwise be ineligible for surgical aortic valve replacement. It may also be useful for patients at high surgical risk by potentially reducing periprocedural complications and avoiding the morbidity and recovery from undergoing heart surgery. Potential harms include the need for conversion to an open procedure, perioperative death, myocardial infarction, stroke, bleeding, valve embolization, aortic regurgitation, heart block that requires a permanent pacemaker, renal failure, pulmonary failure, and major vascular complications such as cardiac perforation or arterial dissection. Potential long-term harms include death, stroke, valve failure or clotting, and endocarditis. As highlighted at the February 2012 California Technology Assessment Forum meeting, the dispersion of this technology to new centers across the United States must proceed with careful thought given to training and proctoring multidisciplinary teams to become new centers of excellence.

CONCLUSIONS

TAVR is a potentially lifesaving procedure that may improve quality of life for patients at high risk for surgical AVR. However, attention needs to be paid to appropriate patient selection, their preoperative evaluation, surgical techniques, and postoperative care to preserve and improve on the results attained in the Placement of Aortic Transcatheter Valve trial. Specialty societies are collaborating to ensure that this happens in a rational and comprehensive manner.

Left ventricular global systolic longitudinal deformation and prognosis 1 year after femoral and apical transcatheter aortic valve implantation

BACKGROUND

Aortic valve replacement is the recommended therapy for patients with severe aortic stenosis who have symptoms or decreased left ventricular (LV) function. Transcatheter aortic valve implantation (TAVI) is a treatment alternative in surgically high-risk or inoperable patients with severe aortic stenosis. The objective of this study was to analyze LV function assessed by global LV longitudinal systolic strain (GLS) and relation to prognosis in patients with severe aortic stenosis treated with femoral or apical TAVI.

METHODS

Two-dimensional echocardiography was performed before and 1 year after TAVI. Ejection fraction (EF) was retrospectively measured using the biplane Simpson's method, and GLS was obtained as an average of 16 segments in the three standard apical views by speckle-tracking. GE Vivid 7 and Vivid 9 machines were used for echocardiography, and speckle-tracking analysis was performed using EchoPAC PC '08 version 7.0.1.

RESULTS

The total population consisted of 100 TAVI patients. Eighty-one patients survived to 1-year follow-up, with a mean age of 81 ± 7 years (range, 64-93 years) and a mean European System for Cardiac Operative Risk Evaluation score of 9.6 ± 2.7. Nineteen patients died before 1-year follow-up (12 women), with a mean age of 82 ± 7 years (range, 66-92 years) and a mean European System for Cardiac Operative Risk Evaluation score of 10.5 ± 2.8. No differences were found between the 19 patients who died before follow-up and the 81 patients who survived to 1-year follow-up. GLS was increased significantly 1 year after TAVI. In 34 patients with EFs > 50%, GLS increased from -15.3 ± 3.4 to -17.1 ± 3.6 (P = .04). In these patients, the mean EF increased numerically from 57.9 ± 5.3% to 60 ± 7.7% (P = .19). In 74 patients with EFs ≤ 50%, mean GLS and EF improved significantly from -10 ± 2.8 to -13.8 ± 3.8 (P < .0001) and 39 ± 9.4% to 52 ± 12.5% (P < .0001), respectively. The 1-year gain in EF was the same after femoral TAVI (9.7 ± 10.1%) and after apical TAVI (8 ± 10.8%) (P = .52). Furthermore, GLS did not differ significantly after femoral and apical TAVI (-3.8 ± 3.3 and -2.6 ± 3.7, respectively, P = .21). There was no difference in causes of death according to approach. In the total population (n = 100), 35 deaths occurred, 19 before 1-year follow-up and 16 afterward. The median follow-up time was 30 months. Twenty-five patients (71%) died from cardiac causes. Overall 1-year mortality was 19%, and overall 2-year mortality was 28%. In the patients who died, the median survival time in the apical group was 28.5 ± 15.4 months, compared with 31.6 ± 19 months in the femoral group (P = .47). There was no impact on prognosis according to high (≥47.5%) versus low (<47.5%) baseline EF or high (≥11.95%) versus low (<11.95%) baseline GLS. However, the magnitude of changes in GLS seemed to have a prognostic impact.

CONCLUSIONS

LV EF and longitudinal systolic deformation were improved in TAVI independent of technical approach using the Edwards SAPIEN valve prosthesis during 1-year follow-up. The mortality rate was comparable between technical approaches and independent of baseline LV function. However, patients with the greatest improvement in LV systolic longitudinal deformation after TAVI had a lower mortality rate.

Multimodality imaging throughout transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is a novel, less-invasive technique used to treat selected patients with severe aortic valve stenosis with a high surgical risk. Noninvasive imaging before, during and after the procedure is of the utmost importance in this minimally invasive procedure. Screening of the patient and sizing of the aortic root by echocardiography and multislice computed tomography is of great importance to ensure success of the TAVI procedure. Echocardiography and fluoroscopy are essential during the procedure. During follow-up of the patients, echocardiography is important to evaluate the prosthesis function, durability and integrity. Additionally, multislice computed tomography and MRI might be helpful in the follow-up of selected cases. This article outlines the evolving role of multimodality imaging throughout TAVI in patients with severe aortic valve stenosis. It describes, in a stepwise approach, how multimodality imaging by echocardiography, angiography, multislice computed tomography and MRI enhances the TAVI procedure.

Prosthesis/annulus discongruence assessed by three-dimensional transoesophageal echocardiography: a predictor of significant paravalvular aortic regurgitation after transcatheter aortic valve implantation

AIMS

Paravalvular aortic regurgitation (AR) is common after transcatheter aortic valve implantation (TAVI). This study aimed to assess the prosthesis/aortic annulus discongruence by three-dimensional (3D) transoesophageal (TOE) planimetry of aortic annulus and its impact on the occurrence of significant AR after TAVI.

METHODS AND RESULTS

We included 33 patients who underwent TAVI with a balloon expandable device for severe aortic stenosis. To appraise the prosthesis/annulus discongruence, we defined a 'mismatch index' expressed as: annulus area - prosthesis area. The aortic annulus area was planimetered with 3D TOE, and approximated by circular area formula (π r(2)) using annulus diameter obtained by two-dimensional (2D) TOE. After TAVI, 13 patients (39.3%) developed significant AR (≥2/4). The occurrence of significant AR was associated to the 3D planimetered annulus area (P = 0.04), and the 'mismatch index' obtained through 3D planimetered annulus area (P = 0.03), but not to 'mismatch index' derived of 2D annulus diameter. In multivariate analysis, 'mismatch index' for 3D planimetered annulus area was the only independent predictor of significant AR (odds ratio: 10.614; 95% CI: 1.044-17.21; P = 0.04). The area under the receiver operating characteristic curve for the 'mismatch index' by the 3D planimetered annulus area was 0.76 (95% CI: 0.54-0.92), whereas for 'mismatch index' obtained by the 2D circular area was 0.36 (95% CI: 0.17-0.55). Using the 3D planimetered annulus area as the reference parameter to decide the prosthetic size, the choice would have been different in 21 patients (63%).

CONCLUSION

Three-dimensional TOE planimetry of aortic annulus improves the assessment of prosthesis/annulus discongruence and predicts the appearance of significant AR after TAVI.

Intracardiac echocardiography: a new guiding tool for transcatheter aortic valve replacement

BACKGROUND

Echocardiography has been debated as an adjunct for transcatheter aortic valve replacement (TAVR). The aim of this prospective study was to comparatively evaluate intraprocedural guidance using intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE).

METHODS

Fifty high-risk patients with severe aortic stenosis scheduled for TAVR were randomized to either guidance using ICE (group 1; n = 25) or monitoring using TEE (group 2; n = 25).

RESULTS

In contrast to TEE, ICE allowed continuous monitoring. The need for probe repositioning during the procedure was much lower in group 1 (0.1 ± 0.3 vs 5.7 ± 0.7 maneuvers, P < .001). Compared with TEE, the transcaval intracardiac echocardiographic view provided higher coaxiality with the ascending aorta expressed as the length of ascending aorta depicted (4.9 ± 1.2 vs 6.1 ± 1.2 cm, P = .003). Both coronary ostia were more frequently visualized in group 1 (18 vs 2 cases, P < .001). ICE-derived annular measurements were correlated closely with preinterventional readings on TEE (n = 25, r(2) = 0.90, P < .001). TEE underestimated intraprocedural pressure gradients in comparison with preinterventional measurements (mean difference, -10.2 ± 11.1 mm Hg; n = 11, P = .012), but ICE did not (mean difference, -0.3 ± 14.1 mm Hg; n = 25, P = .913). ICE and TEE detected newly grown thrombi (2 vs 1 case). Severe complications (e.g., annular dissection, pericardial effusion) were not observed.

CONCLUSIONS

ICE, which is compatible with sedation and local anesthesia, can be considered an alternative to TEE for intraprocedural guidance during TAVR. It also seems to match the required work flow during TAVR better than TEE.

Transcatheter aortic valve replacement: the changing paradigm of aortic stenosis treatment

Aortic stenosis is the most common cause for valvular surgery in the USA. For nearly 50 years, surgical aortic valve replacement has been the standard of care for symptomatic patients; unfortunately, a significant number of patients are not referred to surgery owing to advanced comorbidities and age. Transcatheter aortic valve replacement has emerged as an effective therapy for patients at high risk for surgery. Through device innovations and accumulated experience, the safety and efficacy of the procedure has improved since its inception. Transcatheter valve replacement has been found superior to medical therapy in inoperable patients with aortic stenosis, yet many questions remain as to which patients are appropriate for this exciting and novel therapy.

WITHDRAWN: Very Early Improvement in Valvuloarterial Impedance Induced by Transcatheter Aortic Valve Implantation (CoreValve) in Symptomatic Aortic Stenosis

The editors have requested that the article be withdrawn because of concern that some of its contents appear quite similar to portions of another publication from the same group of investigators. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Left ventricular mass regression one year after transcatheter aortic valve implantation

BACKGROUND

Left ventricular (LV) hypertrophy is associated with LV diastolic dysfunction and constitutes a risk factor for cardiac morbidity and mortality. The objective of this study was to investigate the degree of LV mass regression and the changes of LV diastolic function one year after transcatheter aortic valve implantation (TAVI).

METHODS

Echocardiography was performed at baseline, before discharge, and at one-year follow-up in 63 consecutive patients with severe aortic stenosis who underwent TAVI with the Medtronic CoreValve System (Medtronic Inc, Minneapolis, MN). The LV mass was calculated using the Devereux formula and indexed to body surface area.

RESULTS

One-year all-cause mortality was 29%. The LV mass index decreased from 126 ± 42 g/m(2) at baseline to 110 ± 30 g/m(2) at one-year follow-up (p < 0.001). Left ventricular ejection fraction and LV diastolic function did not change significantly. Mean transaortic gradient decreased from 47 ± 19 mm Hg at baseline to 9 ± 5 mm Hg at discharge and 9 ± 4 mm Hg at one year (p < 0.001), and was accompanied by significant clinical improvement. More than mild paravalvular aortic regurgitation was found in 24% and 15% of patients at discharge and one-year follow-up, respectively.

CONCLUSIONS

A significant regression in LV mass was found one year after TAVI. However, regression was incomplete and was not accompanied by an improvement in LV diastolic function.

Anesthetic considerations of percutaneous transcatheter aortic valve implantation: first attempt in Korea -A report of 2 cases-

Conventional aortic valve replacement for severe aortic stenosis is associated with a high operative mortality in the elderly patients with significant comorbidities, including severe respiratory dysfunction, renal insufficiency, and compromised cardiac function. Human transcatheter aortic valve implantation was first reported in 2002 and has become a valid alternative in selected high-risk patients in Europe and North America. This article describes the first attempt of transfemoral transcatheter aortic valve implantation in Korea. The procedure was applied in two consecutive patients with severe aortic stenosis. Despite several intra-operative complications during procedure, the post-operative outcomes were good for both patients. At post-operative 30 days there was satisfactory prosthetic valve function and hemodynamic stability.

Frequency of conduction abnormalities after transcatheter aortic valve implantation with the Medtronic-CoreValve and the effect on left ventricular ejection fraction

New conduction abnormalities occur frequently after transcatheter aortic valve implantation (TAVI). The relation between new conduction disorders and left ventricular (LV) systolic function after TAVI is unknown. The purpose of the present prospective, single-center study was to investigate the effect of TAVI on LV systolic function in relation to TAVI-induced conduction abnormalities. A total of 27 patients had undergone electrocardiography and transthoracic echocardiography the day before and 6 days after TAVI with the Medtronic-CoreValve system. The LV ejection fraction (EF) was calculated using the biplane Simpson method. The systolic mitral annular velocities and longitudinal strain were measured using speckle tracking echocardiography. After TAVI, 18 patients (67%) had new conduction abnormalities; 4 (15%) had a new paced rhythm and 14 patients (52%) had new left bundle branch block. In the patients with new conduction abnormalities, the EF decreased from 47 ± 12% to 44 ± 10%. In contrast, in those without new conduction abnormalities, the EF increased from 49 ± 12% to 54% ± 12%. The change in EF was significantly different among those with and without new conduction abnormalities (p <0.05). In patients without new conduction abnormalities, an improvement was found in the systolic mitral annular velocities and longitudinal strain (p <0.05). In contrast, in patients with new conduction abnormalities, the changes were not significant. In conclusion, the induction of new conduction abnormalities after TAVI with the Medtronic-CoreValve was associated with a lack of improvement in LV systolic function.

Percutaneous transarterial aortic valve implantation: what do we know?

Transcatheter aortic valve implantation (TAVI) is assuming a major role in the routine management of patients with aortic stenosis. Surgical aortic valve replacement is generally accepted to prolong survival, on the basis of historical comparisons and long experience. However, recently percutaneous transarterial TAVI has assumed the position as the only therapy in any aortic stenosis patient group demonstrated to prolong survival in a randomized trial. Arguably, percutaneous TAVI is now the standard of care in symptomatic patients who are not candidates for conventional surgery. On the basis of almost 10 years of experience TAVI also appears to be a reasonable option for some operable, but high-risk patients. Nevertheless considerable work needs to be done before the indications for TAVI are expanded into lower risk groups. We review what is currently known about percutaneous transarterial implantation of the aortic valve.