Percutaneous aortic valve replacement has come to stay

Received: 13.03.2014 Accepted: 20.05.2014 Percutaneous aortic valve replacement (TAVR) is a cutting-edge technology and one of the breakthroughs in cardiovascular medicine in the last decade and, for these reasons, some considerations must be taken even at risk that some of them might soon become outdated as a result of the exponentially growing medical evidence and experience about this technique 1. The number of patients who could benefit from a TAVR is highly variable in different regions of the world, and many of them do not even have good estimations 2. However, according to an European survey, approximately 30% of those patients with severe aortic stenosis requiring aortic valve replacement (AVR) do not currently receive the proper surgery for different reasons but high surgical risk appears as one of the most common cause for surgery contraindication 3; moreover, considering that global population is aging, I have the expectation that the percentage and total number of patients who can benefit from TAVR will grow dramatically in few years. These estimations can also vary depending on the threshold to indicate TAVR or AVR by open surgery (AVRbyOS) by each Heart Team. This will be influenced by recommendations in guidelines, local experience, and the economic situation of the region, which will affect cost/effectiveness relationship. For example, in Latin America, in those patients where TAVR may be an alternative with similar medical outcomes but more expensive, AVRbyOS will remain as the standard of care. However, in some regions the target will not be this group of patients but rather those requiring AVR having a high risk or contraindication for AVRbyOS. In my opinion, octogenarians without other comorbidities will be the first intermediate risk group that will be electively treated by TAVR in a short time. Patient selection must be performed by a multidisciplinary team with different training and expertise covering all the aspects that are necessary for taking care of this highly complex patient population, working in an adequate environment (Heart Team) 4, 5. However, it is likely that these structures will simplify to make them more efficient, but access to consultations and specific care when required must be kept. This also leads me to a belief that the practice will continue on an upward trend in the use of femoral approach, reserving all the other vascular access for particular situations. Nevertheless, vascular complication rate, which is an important predictor of mortality, should be maintained low and minimized if possible 6–8. Technological developments leading to devices and delivery systems miniaturization with new altogether with better vascular closure devices will facilitate this trend and will make the so call “minimalist approach” to increase. This approach consists of using local anesthesia 9–11, percutaneous access 12, 13 and transthoracic ultrasound for the implantation. The published outcomes with the two most studied devices worldwide are very encouraging despite the initial series have used first-generation devices and included the learning curve of the operators 14–17. Although there are not randomized clinical trials comparing balloon expandable systems vs. self-expanding; there are large series of patients reported which did not show significant differences between them 18, except with valve-in-valve for the treatment of degenerated bioprosthesis, where there has been found a lower residual gradient using the CoreValve (Medtronic’s self-expanding system) 19.