TAVR - HOW, WHEN AND WHY?

Abstract

Transcatheter Aortic Valve Replacement (TAVR) took the world of cardiology likea stormand with the provision of solid evidence based data, it is being accepted inall corners of the world. Very rarely a new technique has been embraced soenthusiastically in spite of the high cost and high technical demand. Thetechnology has found inroads in Pakistan and after the pioneering work at NICVDKarachi, other centres are trying it out. This editorial is an attempt to provideevidence that has been accumulated so far to help us offer this expensivetechnology to the patients, who have been shown to benefit from it. TAVR hasbeen widely accepted as an intervention of choice in elderly patients with severeaortic stenosis (AS) who are either inoperable or have high-surgical risk. It is hasbeen evaluated and recommended for elderly symptomatic intermediate-riskpatients. In asymptomatic, lower-risk patient it is still not being recommended.Undoubtedly, TAVR has emerged as a transformational procedure, which hasalready improved and saved thousands of precious lives. And the future, indeed,appears more promising.1

There are a few grey areas that need more research. Certain groups of patients have been traditionally excluded from thestudies. Patient with low flow and low gradient AS, those with significant CAD, concomitant valvular problem, previous cardiacsurgery and patients with severe LV outflow calcification - all these groups need more studies. Recent registry data showedencouraging results of TAVR for bicuspid AS, but unique challenges remain unconquered relating to orifice size and leafletcalcification. There is little data on TAVR in patients below 75 years of age and for surgical low-risk patients. In such patients 7SAVR remains the modality of choice. Younger patients differ in terms of anatomy many being bicuspid and yet not availablelong termdata as regards long-termdurability data for TAVR prosthetic valves.

To conclude, in general, patients with severe symptomatic AS who are inoperable or offer higher risk profile for SAVR should beconsidered for TAVR. More so, if the device can be delivered via transfemoral approach. Patients of severe symptomatic AS atyounger age and lower risk should be treated with SAVR. With refinement of technology delivery of valve is being simplified andrendered easier. The risk of complications is reducing with shorter hospital stay and more acceptability of the procedure. Thechoice between SAVR and TAVR should be made after a thorough discussion among the heart team and with the patientconsidering age, comorbidities, anatomy and local experience ofsurgery and TAVR of the centre.