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New strategies increase transcatheter aortic valve implantation suitability
8 September 2010
MedWire News: Researchers report that 97% of aortic stenosis (AS) patients are anatomically suitable for transcatheter aortic valve implantation (TAVI) if a two-device strategy is used and transapical, transaxillary, or direct aortic procedural routes are offered in addition to the traditional transfemoral route.
Assessing patients for both an Edwards and a Medtronic CoreValve (M-C) device increases the proportion of patients eligible for TAVI by almost 10% “because the principal limitations for Edwards Sapien (large annular dimension) differ from those for M-C (small annulus dimension),” say Hasan Jilaihawi (Montreal Heart Institute, Quebec, Canada) and team.
They add: “The use of both devices is complementary and makes TAVI available for patients at either end of anatomical requirements.”
The researchers measured the aortic valve annulus and vessel dimensions of 100 high-surgical-risk patients with AS.
Only patients with aortic annular dimensions of 18 to 25 mm and iliofemoral dimensions of 7 or 8 mm (small and large M-C valve, respectively) were deemed suitable for a transfemoral TAVI using an Edwards device.
Suitability for the same procedure using an M-C device was determined by aortic annular dimensions of 20 to 27 mm, iliofemoral dimensions ≥6 mm, and an ascending aorta diameter of <40 or <43 mm (for small and large M-C valve, respectively) at the point 40 mm distal to the aortic annulus.
As published in the Journal of American College of Cardiology: Cardiovascular Interventions, the researchers found that 78% and 84% of patients were suitable for an Edwards (new-generation version) and M-C transfemoral TAVI, respectively.
The remaining patients – those unsuitable for the transfemoral approach - were then evaluated for a transapical Edwards device and a transaxillary or direct ascending aortic access M-C device.
Jilaihawi and team found that the overall number of patients suitable for TAVI increased to 88% and 89% when transapical Edwards and transaxilla/direct M-C routes, respectively, were considered in addition to the transfemoral route.
This proportion of anatomically suitable patients further increased to 97% when patients were assessed for TAVI using either device and by any access route (p=0.004 for Edwards, p=0.008 for M-C-based approach).
Jilaihawi et al comment: “The future expansion of device sizes will increase patient suitability for each system, and the variety of access approaches will ensure that the vast majority of patients can be treated.”
However, in an accompanying editorial, Peter Wenaweser and Stephan Windecker (Bern University Hospital, Switzerland) commented that “evaluation of technical feasibility is only but one important consideration during the screening process.”
They added: “Careful assessment of risk for conventional surgical aortic valve replacement, identification of comorbidities, geriatric assessment, evaluation of frailty, and an interdisciplinary discussion of various therapeutic options should precede evaluation of technical feasibility.”
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