Reducing mortality rates in patients undergoing transcatheter aortic valve implantation

Abstract

Our society is rapidly aging, and this is associated with an increase in the number of patients with cardiovascular disease, such as aortic valve stenosis. In the western world, aortic valve stenosis is predominantly the consequence of valve degeneration, which shares some pathophysiological pathways with atherosclerosis, finally leading to leaflet calcification [1]. With the occurrence of symptoms, current guidelines recommend aortic valve replacement (AVR) [2]; however, numerous people do not undergo surgical valve replacement [3]. There are three main reasons for this: they are considered too ‘old’ or too ‘frail’ and, therefore, are not referred to the cardiac surgeon; the surgeons turn down the operation, predominantly because of the patients higher age or their poor ejection fraction; or the patients refuse surgery because they are afraid or think it is not worth undergoing a cardiosurgical procedure at a higher age [3]. For low-risk patients, which is the vast majority, surgical AVR is still the first-line therapy in patients with severe, symptomatic aortic stenosis [2]. This recommendation is based on the lifesaving and symptom-improving effect of valve replacement in the presence of low mortality rates of surgical AVR. Based on health economic data, for example from Germany, mortality rates are approximately of 3% at 30 days after surgical AVR and are, therefore, considerably lower compared with those in early and recent transcatheter valve studies and registries [4]. This is not surprising given the lower risk profile of patients treated with surgical AVR. For those that do not qualify for conventional AVR, transcatheter aortic valve implantation (TAVI) represents an alternative treatment option. It can be carried out through the femoral, iliac, carotid or subclavian/axillary artery, through a transapical or direct aortic