Percutaneous aortic valve implantation. The demise of classical aortic valve replacement?

Abstract

The Paris group of Descoutures et al. 1 describe their recent experience with percutaneous aortic valve implantation (PAVI). During a 7-month period they were referred 66 elderly patients (>70 years; mean 83 years) for treatment of severe aortic stenosis (AS). Thirty-nine of these (59%) were judged inoperable or ‘high risk’ for surgery. From this subgroup, 12 (31%) were submitted to PAVI and the remaining 27, who were deemed unsuitable for this procedure, were either treated medically (16 patients) or had a catheter balloon dilatation (inappropriately termed valvuloplasty by the authors—seven patients). Perhaps ironically, the last four of these patients, initially deemed inoperable or high risk, were later submitted to classical aortic valve replacement (AVR), because the surgical risk was considered ‘high but not prohibitive’. Two of them also had severe coronary heart disease and underwent combined myocardial revascularization (CABG). The remaining 27 of the initial 66 patients were primarily sent for AVR. This group's results throw light on the problems still facing these procedures. Valve implantation was primarily not successful in two patients (17%) and there were three peri-procedural deaths (25%), for a global failure rate of 33.3%, while among the 27 originally sent for AVR only one patient died early (3%) and there were no further deaths up to 6 months. In contrast, 10% (6/60) of the non-surgical group survivors had died after this short follow-up: two after valvuloplasty and four after medical treatment. Furthermore, none of the four patients who were later redirected towards AVR died, and all had an uneventful recovery. Percutaneous valve implantation was initially directed at the pulmonary valve, first applied by Bonhoeffer in 2000,2 and has been very successful in many hundreds of patients, especially for the treatment of degenerated homografts used for treatment of congenital anomalies with right ventricular outflow tract obstruction. … *Corresponding author. Tel: +351 239400418, Fax: +351 239829674, Email: antunes.cct.huc{at}sapo.pt