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Education in Heart
Future of transcatheter aortic valve implantation: where do we go from here?
  1. Kush P Patel1,2,
  2. Andreas Baumbach2,3
  1. 1 Structural Heart Intervention Department, Barts Heart Centre, London, UK
  2. 2 Barts Heart Centre, Barts Health NHS Trust, London, UK
  3. 3 Cardiology, Queen Mary University of London, London, UK
  1. Correspondence to Professor Andreas Baumbach, Cardiology, Queen Mary University of London, London, UK; a.baumbach{at}qmul.ac.uk

https://doi.org/10.1136/heartjnl-2022-321575

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    Learning objectives

    • To review the preprocedural, periprocedural and postprocedural changes that have taken place in the field of transcatheter aortic valve implantation (TAVI) over the past two decades.

    • To review the expanding indications for TAVI in various populations.

    • To highlight the key areas in need of improvement for the technology and the questions that need answering for the field to progress.

    Introduction

    Over the past two decades since the first transcatheter aortic valve implantation (TAVI) was performed, substantial changes to technique, technology and indications have taken place. TAVI has moved from a challenging procedure with multiple complications in patients at prohibitive surgical risk to an almost day-case procedure used in low-risk patients. As operator experience increased, so did risk stratification, an understanding of the technology’s limitations and a reduction in associated complications. As a front-runner in the treatment of aortic stenosis (AS), the indications for TAVI have expanded rapidly and are continuing to do so. However, this expansion raises important questions regarding valve durability, lifetime management of patients and technological refinements to cater to different populations. This article highlights the changes in the field and provides a perspective on the future of this technology.

    Expanding indications for TAVI

    TAVI started off as an alternative to medical therapy in prohibitive surgical risk patients, before demonstrating non-inferiority, or in some cases superiority, to surgical aortic valve replacement (SAVR) in high-risk, intermediate-risk and low-risk patients.1–4 These pivotal trials laid the foundations for guidelines and benchmark for outcomes. Consequently, TAVI has demonstrated a rapid uptake in its utility, surpassing SAVR as the most common form of treatment for AS in many countries. The rates of TAVI are forecasted to increase, especially given the different phenotypes of AS and aortic regurgitation (AR) currently under investigation with TAVI.

    Younger and lower risk patients

    Although evidence supports the use of TAVI in younger and low-risk patients, certain considerations …

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    Footnotes

    • Contributors KPP, AB: conception and design, data analysis/interpretation, drafting the manuscript, critical revision of the manuscript and final approval of the manuscript. Both authors agree to be accountable for all aspects of this manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests KPP has research grant from Edwards Lifesciences.

    • Provenance and peer review Commissioned; internally peer reviewed.

    • Author note References which include a * are considered to be key references.