Challenges after the first decade of transcatheter aortic valve replacement: Focus on vascular complications, stroke, and paravalvular leak

Christopher Reidy, Aris Sophocles, Harish Ramakrishna, Kamrouz Ghadimi, Prakash A. Patel, John G.T. Augoustides

Research output: Contribution to journalReview articlepeer-review

30 Scopus citations

Abstract

Transcatheter aortic valve replacement (TAVR) is entering its second decade. Three major clinical challenges have emerged from the first decade of experience: vascular complications, stroke, and paravalvular leak (PVL). Major vascular complications remain common and independently predict major bleeding, transfusion, renal failure, and mortality. Although women are more prone to vascular complications, overall they have better survival than men. Further predictors of major vascular complications include heavily diseased femoral arteries and operator experience. Strategies to minimize vascular complications include a multimodal approach and sleeker delivery systems. Although cerebral embolism is very common during TAVR, it mostly is asymptomatic. Major stroke independently predicts prolonged recovery and increased mortality. Identified stroke predictors include functional disability, previous stroke, a transapical approach, and atrial fibrillation. Embolic protection devices are in development to mitigate the risk of embolic stroke after TAVR. PVL is common and significantly decreases survival. Undersizing of the valve prosthesis can be minimized with 3-dimensional imaging by computed tomography or echocardiography to describe the elliptic aortic annulus accurately. The formal grading of PVL severity in TAVR is based on its percentage of the circumferential extent of the aortic valve annulus. Further emerging management strategies for PVL include a repositionable valve prosthesis and transcatheter plugging. The first decade of TAVR has ushered in a new paradigm for the multidisciplinary management of valvular heart disease. The second decade likely will build on this wave of initial success with further significant innovations.

Original languageEnglish (US)
Pages (from-to)184-189
Number of pages6
JournalJournal of Cardiothoracic and Vascular Anesthesia
Volume27
Issue number1
DOIs
StatePublished - Feb 2013

Keywords

  • 3-dimensional transesophageal echocardiography
  • Valve Academic Research Consortium
  • annular circumference
  • annular sizing
  • atrial fibrillation
  • bleeding
  • dissection
  • elliptic aortic annulus
  • embolic protection device
  • fistula
  • hematoma
  • mortality
  • multidetector computed tomography
  • operator experience
  • paravalvular leak
  • pseudoaneurysm
  • renal failure
  • rupture
  • sheath diameter
  • standardized definitions
  • stroke
  • transcatheter aortic valve replacement
  • transfusion
  • vascular complications

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Anesthesiology and Pain Medicine

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