Considerations for Optimal Device Selection in TAVR

Many studies have tried to answer the question about whether there is a superior device in transcatheter aortic valve replacement (TAVR). Today, there is no evidence to support such claim, and most patients will likely find operator experience more beneficial than any device per se.  

However, there are certain patients with specific characteristics that might benefit from one device more than others. 

The presence of calcium at annular or sub-annular level and the need to eventually re-access the coronary arteries can influence the decision. 

The 5 year followup of the CHOICE study recently published was not able to show differences in 241 high risk patients treated with  the self-expandable CoreValve vs. the balloon expandable Sapien XT. Hemodynamics favored the CoreValve and structural deterioration resulted infrequent for both valves (slightly more frequent for Sapien XT).

Two observational studies published last year reported a smaller chance of paravalvular regurgitation with the balloon expandable valve and even lower mortality. These outcomes are provoking, but the registries have limitations. 

Read also: Visual Assessment for Non-Culprit Lesion Revascularization.

The randomized studies head to head give us a pretty good idea, but they have been designed to include ideal patients that make good candidates for any device. This is exactly the opposite of what we seek to clarify: what patients are better suited for each device. 

Coronary calcification, risk of obstruction and the need to re-access might tilt the scales. Severe calcification of the outflow tract might support the self-expandable vs. the Sapien. 

Other factors that might influence valve selection are aortic arch angulation, coronary sinus size, system release profile, risk of paravalvular leak and need for pacemaker implantation. 

Read also: Computerized Tomography as First Coronary Study?

Patients with conduction disorders such as right bundle branch block or with a very short membranous septum might be better candidates for the balloon expandable valve. 

Future coronary re-access might tilt the scales in favor of the balloon expandable valve. This is especially true in young patients seeing as they have higher life expectancy and therefore higher chances of future CAD.

Preliminary studies are being carried out on other valves such as the JenaValve and the J-Valve which have been designed to treat pure native aortic regurgitation in addition to stenosis.

Read also: Outflow Tract Calcification and the Best Valve in This Context.

Research on the self-exandable valves Acurate neo and Portico is more advanced.

Original Title: Considerations for optimal device selection in transcatheter aortic valve replacement: a review.

Reference: Claessen BE et al. JAMA Cardiol. Published online September 9, 2020.doi:10.1001/jamacardio.2020.3682.

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.