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Minimally invasive TAVI set to replace open heart surgery as the reference treatment for aortic stenosis 

By Professor Simon Redwood

What is the TAVI procedure?

The Transcatheter Aortic Valve Implantation (TAVI) is a minimally invasive procedure in which a prosthetic valve is fed through a small incision in the thigh and implanted into the diseased aortic valve. Unlike surgical aortic valve replacement, which requires an incision the full length of the chest, the TAVI procedure can be carried out with just a single stitch.

 

Professor Simon Redwood leads the TAVI Surgical Intervention Team at Guy’s and St Thomas’ NHS Foundation Trust and is immediate Past-President of the British Cardiovascular Intervention Society.  He is also a lead member of the specialist cardiac team at London Bridge Hospital’s Cardiac Centre of Excellence.


What is aortic stenosis? 

Aortic stenosis is the most common heart valve disease in the world. It is caused by progressive calcification of the aortic valve, and occurs in around one in three people aged over 65. It is often undetected until it has reached an advanced stage. Severe aortic stenosis results in the heart being unable to adequately pass blood and oxygen around the body through the blood stream. If left untreated, its progression will eventually almost certainly be fatal.


Image: Professor Simon Redwood runs an active research team and is lead editor of a major interventional cardiology textbook (Oxford Textbook of Interventional Cardiology).

So in the early 2000s, interventional cardiologists like myself began researching minimally invasive procedures as an alternative to surgery; undertaking trials for a new procedure called the Transcatheter Aortic Valve Implantation (TAVI). 

 

For high risk patients – often elderly, and with complex co-morbidities - the TAVI was transformational. A study of inoperable patients published in The New England Journal of Medicine showed that one-year post-implantation, the TAVI had lowered rates of death and rehospitalisation, decreased symptoms and improved heart function1.

Nearly 20 years have now passed since the first TAVI procedure. In that time, post-procedure complications have reduced as long-term outcomes have continued to improve; giving us new opportunities to explore the use of the TAVI with a wider cohort of lower risk patients.

One major area of development has been in the highly sophisticated diagnostic tools that are essential to pre-procedure planning. Across our Cardiac Centres of Excellence at London Bridge Hospital, The Harley Street Clinic, and The Wellington Hospital, three-dimensional echocardiography and multi-slice computed tomography allow us to build three-dimensional pictures of the heart before any decision about treatment is made. This next-generation technology is helping us to understand disease progression, and create intricate images of the structure, electrical rhythm and blood flow of each patient’s heart. 

 

Today, we select TAVI prostheses from a range of sizes, based on the exact extent of calcification and suitability for the individual patient. The most recent large scale, randomised trial of TAVI patients at low surgical risk, published in March 2019, found that the rate of death, stroke, or rehospitalisation amongst such patients fitted with a balloon expandable valve was “significantly lower” one year after treatment compared to if they had undergone surgery2.

As we undertake more research to identify the optimum point at which to intervene in the progression of aortic stenosis, we believe that randomised trials of all cohorts of patients are the next major and exciting step for the future of the TAVI. Within a few years, with a greater understanding of longer term valve durability, there is little doubt that the vast majority of patients with aortic stenosis will benefit from this minimally invasive treatment as standard clinical practice.

Advances in the treatment of heart disease

Surgical Aortic Valve Replacement (SAVR) has long been regarded as the gold standard treatment for aortic stenosis. It is a major operation, requiring open heart surgery and replacement of the diseased heart valve with a prosthetic one. 

Until the start of the twenty first century, around one in three patients were deemed too high risk to undergo SAVR for treatment of aortic stenosis. With prevalence increasing, and no medication proven to halt or reverse its progression, inoperable patients were presented with a grave cocktail of potential consequences, including sudden cardiac death or heart failure.

Like many cardiac diseases, early intervention through cardiovascular screening is key. Yet for most patients, aortic stenosis goes unnoticed for many years; silently calcifying the aortic valve until symptoms, such as shortness of breath, dizziness and chest pain, signal that the disease has advanced to a critical state. 

References

1, Makkar RR, Fontana GP, Jilaihawi H, Kapadia S, Pichard AD, Douglas PS, et al. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med 2012; 366:1696–704
2, Mack M, Leon M, Thourani V et al, Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med 2019; 380:1695-1705

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