The Intricacies of TAVR
The attention of health care professionals worldwide is currently focused on the devastating consequences of COVID-19 infection. Cardiologists are very much on the front line, not only caring for those with direct and indirect cardiovascular consequences but also supporting intensive care colleagues in the provision of advanced respiratory support for patients with the most extreme manifestations of the condition.
As a direct consequence, structural heart programs have been appropriately suspended in many institutions to liberate resources required elsewhere. As time passes, this will also place an increasing burden as patients with severe valvular heart disease (particularly those with aortic stenosis) require hospitalization as a result of the hemodynamic consequences of progressive disease.
Demand for transcatheter aortic valve replacement (TAVR) will therefore not go away, and the present issue summarizes key developments in the field.
We begin with an article by Sophia L. Alexis, MD; Aditya Sengupta, MD; and Gilbert H.L. Tang, MD, in which they review the technical aspects, current limitations, and future direction of TAVR in aortic insufficiency.
Bicuspid aortic valve disease presents unique challenges. Hussein Rahim, MD; Mariusz Wolbinski, MD; Vinayak Bapat, MBBS; and Tamim M. Nazif, MD, take a look at the next frontier of this challenging patient subset.
Shane P. Prejean, MD; Mustafa I. Ahmed, MD; and Kyle W. Eudailey, MD, provide a summary of the contemporary alternative access routes for TAVR.
Walid Ben-Ali, MD, and Thomas Modine, MD, take a look at where the evidence for TAVR is taking us and how it may impact heart teams.
The long-term durability of TAVR bioprostheses is unknown. Paolo D’Arrigo, MD, and Davide Capodanno, MD, guide us through the definitions, mechanisms, and treatment options surrounding structural valve deterioration and bioprosthetic valve failure.
Nicolas M. Van Mieghem, MD, and Thijmen W. Hokken, MD, provide a thought-provoking discussion about cerebral protection during structural heart interventions, focusing on who, when, and why to use it.
Rebecca T. Hahn, MD, closes our focus on TAVR by asking the question of when prosthesis-patient mismatch really occurs in TAVR, with an accompanying assessment of the current evidence.
Elsewhere in this issue, in our Techniques column, Jason R. Wollmuth, MD, highlights a single-access technique for Impella-assisted (Abiomed, Inc.) high-risk percutaneous coronary intervention and reviews access placement, sheath options, and limitations of the technique.
Our Today’s Practice article by Joel Sauer, MBA, and Terri McDonald, RN, takes a look at the foundational attributes required for aligning a cardiovascular program in an attempt to highlight why physician-hospital alignment still eludes many integrated programs.
Finally, we close this issue with an interview with Stephen J.D. Brecker, MD, who shares how his idea for a TAVR-specific guidewire became a reality, his work with patient-specific computed TAVR simulation, advice to prevent patient-prosthesis mismatch, and much more.
We hope that you will find this issue of Cardiac Interventions Today informative and useful in your practice and a stimulating diversion from the challenges provided by COVID-19. Please stay safe and healthy in these testing times.
Bernard Prendergast, DM, FRCP, FESC
Isaac George, MD
Guest Chief Medical Editors