MAY - 202219PERSPECTIVES ON THE CURRENT LANDSCAPE OF TRANSCATHETER THERAPIES FOR AORTIC AND MITRAL VALVE DISEASEGilbert H. L. Tang, Surgical Director, Structural Heart Program, Mount Sinai Hospital and Aditya Sengupta, Cardiothoracic Surgery Resident, Mount Sinai HospitalByIntroductionValvular heart disease affects 2-3 percent of the U.S. population and is responsible for approximately 25,000 deaths annually. While the majority of patients may benefit from surgical interventions, these procedures are not without risk. This is especially true in older patients who tend to also present with more comorbidities. In the recent past, transcatheter valve therapies have evolved as viable alternatives to open-heart surgery. A few of these notable technologies in the realms of aortic and mitral valve disease are briefly discussed next.Aortic Valve DiseaseSevere and symptomatic calcific aortic stenosis (AS), the most prevalent disease of the aortic valve, has historically been treated with surgical aortic valve replacement (SAVR). While the first catheter-based approach of treating AS was performed in 1985 (balloon aortic valvuloplasty) as an alternative to SAVR in inoperable patients, the modern era of transcatheter valve therapies was ushered in by the advent of transcatheter aortic valve replacement (TAVR) in 2002. Since then, numerous clinical trials have validated the clinical use of TAVR in a variety of patient settings, and TAVR has now become the standard of care for patients with symptomatic heart disease due to severe native calcific AS across the surgical risk spectrum. However, a number of issues continue to impact outcomes, including a lack of data on long-term valve durability and hemodynamics (particularly in low surgical risk patients), prosthesis-patient mismatch (PPM), risk of stroke and new persistent conduction abnormalities, vascular access complications, coronary reaccess and the risk of coronary occlusion, the feasibility of valve-in-valve TAVR, and the use of TAVR in patients with bicuspid aortic valve disease.There are several devices available to TAVR operators. The U.S. Food and Drug Administration (FDA)-approved current-generation transcatheter heart valves (THVs) include the SAPIEN 3, SAPIEN 3 Ultra (Edwards Lifesciences LLC), and Evolut PRO+ (Medtronic Inc) devices. THVs under clinical investigation include the ACURATE neo2 (Boston Scientific), Portico(Abbott), JenaValve, and J-valve systems. These devices differ with regards to their mode of expansion (balloon-expandable versus self-expanding), leaflet position (intra- or supra-annular), frame material, ability to be repositioned, leaflet tissue material, and delivery sheath sizes. Factors to consider when choosing the optimal TAVR device include expected post-procedural hemodynamic parameters (e.g., supra-annular self-expanding devices are generally associated with lower mean gradients and larger effective orifice areas), annular size, and anatomy (e.g., supra-annular THVs may be advantageous in patients with small annuli), the degree of the aortic valve and root calcification, the expected risk of a conduction abnormality (e.g., device implantation depth may need to be adjusted for patients with shorter membranous septal lengths), and the risk of coronary occlusion. Ultimately, a thorough review of each patient's anatomic suitability for TAVR by the Heart Team is mandatory for successful outcomes.Gilbert H. L. TangCXO insights
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