Percutaneous aortic valve replacement

Percutaneous aortic valve replacement
Other namesTranscatheter aortic valve implantation
SpecialtyInterventional cardiology
ComplicationsStroke risk is 4-5% higher in the high-risk patients compared to SAVR[1]
OutcomesSuccessful rate: 92%.[1]

Percutaneous aortic valve replacement (PAVR), also known as percutaneous aortic valve implantation (PAVI), transcatheter aortic valve implantation (TAVI) or transcatheter aortic valve replacement (TAVR), is the replacement of the aortic valve of the heart through the blood vessels (as opposed to valve replacement by open heart surgery). The replacement valve is delivered via one of several access methods: transfemoral (in the upper leg), transapical (through the wall of the heart), subclavian (beneath the collar bone), direct aortic (through a minimally invasive surgical incision into the aorta), and transcaval (from a temporary hole in the aorta near the belly button through a vein in the upper leg), among others.

Severe symptomatic aortic stenosis carries a poor prognosis. No medical cure exists today, making the timing of aortic valve replacement the most important decision to make for these patients.[2] Until recently, surgical aortic valve replacement was the standard of care in adults with severe symptomatic aortic stenosis. However, the risks associated with surgical aortic valve replacement are increased in elderly patients and those with concomitant severe systolic heart failure or coronary artery disease, as well as in people with comorbidities such as cerebrovascular and peripheral arterial disease, chronic kidney disease, and chronic respiratory dysfunction.

Medical uses

Patients with symptomatic severe aortic stenosis have a mortality rate of approximately 50% at 2 years without intervention.[3] In patients who are deemed too high risk for open heart surgery, TAVR significantly reduces the rates of death and cardiac symptoms.[4] At present, TAVR is not routinely recommended for low risk patients in favor of surgical aortic valve replacement, however it is increasingly being offered to intermediate risk patients, based on recent studies showing it to be non-inferior to surgical aortic valve replacement.[5]

Transapical TAVR is reserved for patients for whom other approaches are not feasible: an evidence-based BMJ Rapid Recommendation[6] made a strong recommendation against transapical TAVR in people who are also candidates for either transfemoral TAVR or surgery.[7] People who have the option of either transfemoral TAVR or surgical replacement are likely to choose surgery if they are younger than 75 and transfemoral TAVR if they are older than 75.[7] The rationale for age-based recommendations is that surgical aortic valve replacements are known to be durable long-term (average of durability of 20 years) so people with longer life expectancy would be at higher risk if TAVR durability is worse than surgery.[8]

Devices

Medtronic's CoreValve Transcatheter Aortic Valve is constructed of a self-expanding Nitinol frame and delivered through the femoral artery. This device received FDA approval in January 2014.[9][10][11]

Boston Scientific's Lotus Valve system was awarded CE approval in October 2013. It allows the final position to be assessed and evaluated before release and has been designed to minimise regurgitation.[11]

St Jude Medical's Portico Transcatheter aortic valve received European CE mark approval in December 2013. The valve is repositionable before release to ensure accurate placement helping to improve patient outcomes.[11]

Edwards' Sapien aortic valve is made from bovine pericardial tissue and is implanted via a catheter-based delivery system. It is approved by the FDA for use in the US.[9][10][11]

Implantation

The devices are implanted without open heart surgery. The valve delivery system is inserted in the body, the valve is positioned and then implanted inside the diseased aortic valve, and then the delivery system is removed. The catheter based delivery system can be inserted into the body from one of several sites.[12]

The transfemoral approach requires the catheter and valve to be inserted via the femoral artery. Similar to coronary artery stenting procedures, this is accessed via a small incision in the groin, through which the delivery system is slowly fed along the artery to the correct position at the aortic valve. A larger incision in the groin may be required in some circumstances.[12]

The transapical approach sees the catheter and valve inserted through the tip of the heart and into the left ventricle. Under general anesthesia, a small surgical incision is made between the ribs, followed by a small puncture of the heart. The delivery system is then fed slowly to the correct position at the aortic valve. The puncture in the heart is then sutured shut.[12]

The transaortic approach sees the catheter and valve inserted through the top of the right chest. Under general anesthesia, a small surgical incision is made alongside the right upper breastbone, followed by a small puncture of the aorta. The delivery system is then fed slowly to the correct position at the aortic valve. The hole in the aorta is then sutured shut.[12]

The transcaval approach has been applied to a smaller number of patients who are not eligible for transfemoral, transapical, or transaortic approaches. In the transcaval approach a tube is inserted via the femoral vein instead of the femoral artery, and a small wire is used to cross from the inferior vena cava into the adjacent abdominal aorta. Once the wire is across, a large tube is used to place the transcatheter heart valve through the femoral vein and inferior vena cava into the aorta and from there the heart. This otherwise resembles the transfemoral approach. Afterwards, the hole in the aorta is closed with a self-collapsing nitinol device designed to close holes in the heart.[13][14]

In the subclavian approach, an incision is made under the collar bone under general anesthesia, and the delivery system is advanced into the correct position in the aortic valve. The delivery system is then removed and the incision is sutured closed.

Complications

When PAVR surgery is performed an important and difficult aspect that affects the patient is the orientation, uniformity and depth at which it is inserted. When the valve is not inserted correctly, when there is incomplete sealing between the native heart valve and the stented valve, paravalvular leak (PVL) can occur. Key properties associated with paravalvular leak are the regurgitation volume, the PVL orifice location (anterior or posterior) and the associated fluid dynamic effects that occur from the interactions between the regurgitated flow and the normal transmitral flow.

Morisawa et al.[15] performed a quantitative to determine how the PVL flow effected normal transmitral flow based on three different in-vitro situations: no PVL, anterior orifice PVL and posterior orifice PVL. The results showed that while the two PVL cases negatively impacted the fluid dynamics of the normal transmitral flow seen in the no PVL case the posterior orifice PVL was a worse case scenario. The posterior orifice PVL led to a higher circulation and kinetic energy which translates to requiring the heart to work harder and consume more energy to maintain normal bodily functions.

History

The catheter procedure was invented and developed in Aarhus University Hospital Denmark in 1989 by Henning Rud Andersen,[16] who performed the first animal implantations the same year.[17] The first implantation in a patient was performed on 16 April 2002 by Alain Cribier in Hopital Charles Nicolle, at the University of Rouen, France.[18] Technology experts Stan Rowe and Stan Rabinowitz partnered with physicians Alain Cribier, Mehmet Oz and Marty Leon, the latter pair at NewYork–Presbyterian, and others to create Percutaneous Valve Technologies (PVT) in 2002. The company was purchased by Edwards Lifesciences in 2004 and became the Sapien valve, the first aortic valve device to receive FDA approval.[19][20] It received FDA approval in November 2011 for use in inoperable patients and in October 2012 for use in patients at high surgical risk.[21] The device is effective in improving functioning in the patients with severe aortic stenosis. It is now approved in more than 50 countries.

Mick Jagger had the procedure in March 2019 at NewYork–Presbyterian.[22] This was said to have raised public awareness.[23]

References

  1. 1 2 Rajput, FA; Zeltser, R (2020), "article-31500", Aortic Valve Replacement, Treasure Island (FL): StatPearls Publishing, PMID 30725821, retrieved 29 March 2020
  2. ↑ Otto, Catherine M.; Prendergast, Bernard (21 August 2014). "Aortic-Valve Stenosis — From Patients at Risk to Severe Valve Obstruction". New England Journal of Medicine. 371 (8): 744–756. doi:10.1056/NEJMra1313875. PMID 25140960.
  3. ↑ Circulation. 1968 Jul;38(1 Suppl):61-7. Aortic stenosis. Ross J Jr, Braunwald E.
  4. ↑ N Engl J Med. 2010 Oct 21;363(17):1597-607. doi: 10.1056/NEJMoa1008232. Epub 2010 Sep 22. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. Leon MB1, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Brown DL, Block PC, Guyton RA, Pichard AD, Bavaria JE, Herrmann HC, Douglas PS, Petersen JL, Akin JJ, Anderson WN, Wang D, Pocock S; PARTNER Trial Investigators.
  5. ↑ N Engl J Med. 2017 Apr 6;376(14):1321-1331. doi: 10.1056/NEJMoa1700456. Epub 2017 Mar 17. Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients. Reardon MJ, Van Mieghem NM, Popma JJ, Kleiman NS, Søndergaard L, Mumtaz M, Adams DH, Deeb GM, Maini B, Gada H, Chetcuti S, Gleason T, Heiser J, Lange R, Merhi W, Oh JK, Olsen PS, Piazza N, Williams M, Windecker S, Yakubov SJ, Grube E, Makkar R, Lee JS, Conte J, Vang E, Nguyen H, Chang Y, Mugglin AS, Serruys PW, Kappetein AP; SURTAVI Investigators.
  6. ↑ Siemieniuk RA, Agoritsas T, Macdonald H, Guyatt GH, Brandt L, Vandvik PO (2016). "Introduction to BMJ Rapid Recommendations". BMJ. 354: i5191. doi:10.1136/bmj.i5191. PMID 27680768. S2CID 32498374.
  7. 1 2 Vandvik PO, Otto CM, Siemieniuk RA, Bagur R, Guyatt GH, Lytvyn L, Whitlock R, Vartdal T, Brieger D, Aertgeerts B, Price S, Foroutan F, Shapiro M, Mertz R, Spencer FA (2016). "Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline". BMJ. 354: i5085. doi:10.1136/bmj.i5085. PMID 27680583.
  8. ↑ Foroutan F, Guyatt GH, O'Brien K, et al. (2016). "Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies". BMJ. 354: i5065. doi:10.1136/bmj.i5065. PMC 5040922. PMID 27683072.
  9. 1 2 Medscape. "Transcatheter Aortic Valve Replacement Devices". Retrieved December 2013.
  10. 1 2 Agarwal S, et al. (February 2015). "Transcatheter aortic valve replacement: current perspectives and future implications". Heart. 101 (3): 169–77. doi:10.1136/heartjnl-2014-306254. PMID 25410500. S2CID 21098757.
  11. 1 2 3 4 Abdel-Wahab M, et al. (February 2015). "Update on transcatheter aortic valve replacement". Trends Cardiovasc. Med. 25 (2): 154–161. doi:10.1016/j.tcm.2014.10.001. PMID 25453986.
  12. 1 2 3 4 "Technical aspects of transcatheter aortic valve implantation (TAVI)". www.escardio.org.
  13. ↑ Steinberger, JD; McWilliams JP; Moriarty JM (10 April 2015). "Alternative Aortic Access: Translumbar, Transapical, Subclavian, Conduit, and Transvenous Access to the Aorta". Tech Vasc Interv Radiol. 18 (2): 93–99. doi:10.1053/j.tvir.2015.04.007. PMID 26070621.
  14. ↑ Greenbaum, AB; ONeill WW; Paone G; Guerrero M; Wyman JF; Cooper RL; Lederman RJ (1 July 2014). "Caval-aortic access to allow transcatheter aortic valve replacement in otherwise ineligible patients. Initial human experience". J Am Coll Cardiol. 63 (25 Pt A): 2795–2804. doi:10.1016/j.jacc.2014.04.015. PMC 4105161. PMID 24814495.
  15. ↑ Morisawa, Daisuke; Falahatpisheh, Ahmad; Avenatti, Eleonora; Little, Stephen H.; Kheradvar, Arash (23 October 2018). "Intraventricular Vortex Interaction between Transmitral Flow and Paravalvular Leak". Scientific Reports. 8 (1): 15657. Bibcode:2018NatSR...815657M. doi:10.1038/s41598-018-33648-9. ISSN 2045-2322. PMC 6199255. PMID 30353062.
  16. ↑ Grigorios T, Stefanos D, Athanasios M, Ioanna K, Stylianos A, Periklis D, George H (January 2018). "Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis". J Geriatr Cardiol. 15 (1): 76–85. doi:10.11909/j.issn.1671-5411.2018.01.002. PMC 5803541. PMID 29434629.
  17. ↑ Andersen HR, Knudsen LL, Hasenkam JM (May 1992). "Transluminal implantation of artificial heart valves. Description of a new expandable aortic valve and initial results with implantation by catheter technique in closed chest pigs". Eur. Heart J. 13 (5): 704–8. doi:10.1093/oxfordjournals.eurheartj.a060238. PMID 1618213.
  18. ↑ Cribier, A; Eltchaninoff H; Bash A; Borenstein N; Tron C; Bauer F; Derumeaux G; Anselme F; Laborde F; Leon MB (10 December 2002). "Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis. First human case description". Circulation. 106 (24): 3006–3008. doi:10.1161/01.cir.0000047200.36165.b8. PMID 12473543.
  19. ↑ TAVR: Still the Next Big Thing in Cardiology?
  20. ↑ Sapien Transcatheter Aortic Heart Valve Gains FDA Approval
  21. ↑ https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm278348.htm
  22. ↑ "Mick Jagger makes first public appearance since undergoing heart surgery". NME. 24 April 2019.
  23. ↑ "TAVR Puts the Swagger Back in Mick Jagger". MDI online. 10 April 2019. Retrieved 12 April 2019.

Further reading

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