Minimally invasive surgical and transcatheter interventions for aortic valve incompetence: current concepts and future perspectives

We are currently witnessing rapid evolution in minimally invasive surgical (MI-AVS) and transcatheter (TAVR) techniques and innovations for the treatment of aortic valve disease. Current TAVR technology approved for the treatment of aortic valve stenosis do not consistently perform favorably in non-calcified aortic valve regurgitation (AR). Surgical aortic valve repair (AVr) by conventional midline sternotomy is generally accepted as the contemporary "gold standard" intervention, while prosthetic aortic valve replacement and the well-known Ross procedure as a biological alternative to AVr, are reserved for patients who are at risk of early repair failure. AVr offers potential benefits over prosthetic replacement in younger patients with contraindications to long term anticoagulation and life-expectancies greater than the expected structural prosthetic valve degeneration. Even though excellent AVr outcomes are achieved in high-volume expert centers, it is generally regarded to be technically challenging, have significant learning curves and is subsequently infrequently performed by inexperienced surgeons. However, MI-AVS is now the routine approach for isolated aortic valve surgery in various cardiac centers and reports that describe minimally invasive AVr outcomes are progressively emerging. This article outlines the current role and future perspectives of contemporary AR repair techniques by MI-AVS and describes the ongoing evolution of exciting TAVR technology designed specifically for the treatment of non-calcified AR.