1. EXPANDING INDICATIONS OF TRANSCATHETER HEART VALVE INTERVENTIONS. JACC CARDIOVASCULAR INTERVENTION. DR.RAJAT GANDHI

2. INTRODUCTION TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) HAS BEEN ESTABILISHED AS A LESS INVASIVE ALTERNATIVE TO OPEN HEART SURGERY IN INOPERABLE OR HIGH RISK PATIENTS PRESENTING WITH SYMPTOMATIC SEVERE AORTIC STENOSIS.

3. INTRODUCTION TAVR FEASIBILITY AND EFFICACY OF VALVE IN VALVE IMPLANTATION IN DEGENERATED SURGICAL AORTIC BIOPROSTHESIS HAS ALSO BEEN DESCRIBED AND IS CONSIDERED VALUABLE TREATMENT OPTION IN PATIENTS WHO ARE UNSUITABLE FOR REPEAT CARDIAC SURGERY.

4. INTRODUCTION CLINICAL USE OF TVR IS NOT LIMITED TO AORTIC VALVE STENOSIS BUT SEVERAL OTHER CONDITIONS LIKE AORTIC REGURGITATION, VALVE IN VALVE AND VALVE IN RING IMPLANTATION IN MITRAL AND TRICUSPID POSITION, AS WELL AS TREATMENT OF PURE MITRAL, TRICUSPID AND PULMONARY REGURGITATION.

5. AIM AIM OF THE PRESENT REVIEW IS TO SUMMARIZE THE AVAILABLE EVIDENCE CONCERNING THE EMERGING USE OF TVR DEVICES IN CURRENT CLINICAL PRACTISE.

6. EVIDENCE IN PAST 10 YRS,TAVR HAS EMERGED AS VALUABLE MINIMALLY INVASIVE TREATMENT OPTION FOR PATIENTS WITH SEVERE AORTIC STENOSIS. PARTNER TRIAL SHOWED SIGNIFICANT MORTALITY REDUCTION IN INOPERABLE PATIENTS OVER PERIOD OF 5 YRS WITH SIMILAR SAFETY AND EFFICACY AS COMPARED TO SURGICAL AVR.

7. GUIDELINES ON THE BASIS OF THE DATA,TAVR IS RECOMMENDED IN INOPERABLE PATIENTS WITH SYMPTOMATIC AORTIC STENOSIS WITH LIFE EXPECTANCY OF MORE THAN ONE YEAR (CLASS IB). ALTERNATIVE TO SURGICAL TREATMENT IN PATIENTS WITH INCREASED SURGICAL RISK(CLASS IIA) IN BOTH AMERICAN AND EUROPEON GUIDELINES).

8. TAVR FOR PURE AORTIC VALVE REGURGITATION. PURE AR IS LESS FREQUENT THAN AS. IMPLANTATION OF CONVENTIONAL TRANSCATHETER VALVES IN AR IS RECOMMMENDED IN PATIENTS WITH HIGH RISK FOR OPEN HEART SURGERY. TO OVERCOME ANATOMICAL AND TECHNICAL ISSUES,TWO PIGTAIL CATHETERS AND TEE VISUALISATION IS REQUIRED.

9. TAVR FOR AR

10. TRANSFEMORAL TAVR FOR PURE AR

11. TAVR FOR AR TAVR FOR AR IS ASSOCIATED WITH LOWER DEVICE SUCCESS RATE, HIGHER RATE OF MODERATE TO SEVERE AR AND INCREASED RATE OF ALL CAUSE MORTALITY. DEDICATED DEVICES FOR AR LIKE TRANSAPICAL JENA VALVE SHOWED SUSTAINED SYMPTOMATIC IMPROVEMENT AND GOOD HAEMODYNAMIC PERFORMANCES.

12. TAVR IN BICUSPID AORTIC VALVE BAV IS MOST FREQUENT CONGENITAL HEART DEFECT. IN 50 % OF CASES, VALVULAR ANATOMIC CHANGES COEXIST WITH DILATATION OF AORTIC ROOT AND ASCENDING AORTA. TAVR IN BAV REMAINS CHALLENGING DUE TO LARGE ANATOMY, CALCIFICATION AND DISEASED AORTIC ROOT.

13. TAVR IN BICUSPID AORTIC VALVE

14. TAVR IN BAV IN MOST OF THE STUDIES, TAVR IN BAV IS ASSOCIATED WITH MODERATE TO SEVERE PARAVALVULAR LEAK, IF VALVE SIZING WAS DONE WITH ECHOCARDIOGRAPHY. PRE PROCEDURAL CT OF AORTIC ROOT IS VERY IMPORTANT TO MINIMISE THE COMPLICATIONS.

15. TAVR FOR STENOTIC BAV

16. TAVR FOR TRANSCATHETER AORTIC VALVE DEGENERATION IMPLANTATION OF SECOND TRANSCATHETER HEART VALVE FOR TREATMENT OF DEVICE EMBOLISATION OR FOR HAEMODYNAMICALLY SIGNIFICANT PARAVALVULAR LEAK. DEGENERATION DUE TO MECHANICAL STRESS,IMMUNOLOGICAL REACTION,CALCIFICATION AND GENERALISED ATHERSCLEROSIS HAVE BEEN IDENTIFIED AS PRECIPITATING FACTORS.

17. TAVR FOR TRANSCATHETOR AORTIC VALVE DEGENERATION. LONG TERM CLINICAL OUTCOME AFTER TAVR UP TO 6 YRS,THE INCIDENCE OF STRUCTURAL VALVE FAILURE IS LOW RANGING BETWEEN 1.4%-4.1%. IN PARTNER TRIAL, NO VALVE DEGENERATION HAS BEEN OBSERVED,DURING FOLLOW UP AS LONG AS 5 YRS IN >500 TAVR RECEIPIENTS.

18. MITRAL VIV IMPLANTATION REOPERATION AFTER MITRAL VALVE INTERVENTION IS ASSOCIATED WITH INCREASED PERIOPERATIVE MORTALITY AND MORBIDITY EXCEEDING 15% IN PATIENTS 75 YRS OF AGE AND OLDER. TRUE INTERNAL DIAMETER OF THE SURGICAL VALVE IS PRECISELY ASSESSED BY TEE AND MULTISLICE CT SCAN.

19. MITRAL VIV IMPLANTATION IN THE PRESENCE OF CALCIFIC MATERIAL OR PANNUS,THE TRUE INTERNAL DIAMETER CAN BE SMALLER. MAJORITY OF MITRAL VIV IMPLANTATION IS PERFORMMED BY BALLOON EXPANDABLE EDWARDS SAPIEN XT VALVE VIA TRANSAPICAL ROUTE.

20. MITRAL VIV IMPLANTATION

21. MITRAL VIR IMPLANTATION ESV HAS MOST OF THE PUBLISHED DATA IN VIR IMPLANTATIONS VIA TRANS APICAL ROUTE. MITRAL VIR PROCEDURE IS MORE COMPLEX DUE TO MANY REASONS LIKE COMPLETE RIGID RINGS, ELLIPTICAL SHAPE AND PROPER VALVE SIZING. MSCT SCAN ALLOW ACCURATE DIMENSIONS OF VALVE RING.

22. MITRAL VIV AND VIR TRIALS

23. TRICUSPID VALVE IN VALVE IMPLANTATION CARDIAC SURGERY FOR THE TREATMENT OF TR IS ASSOCIATED WITH HIGH MORTALITY OF UP TO 10 %. SEVERAL TECHNICAL ISSUES TO BE CONSIDERED LIKE ROUTE, VALVE SIZE. YOUNG EBSTEIN PATIENTS REQUIRING MULTIPLE VALVE REPLACEMENTS. ESV AND MELODY VALVES ARE COMMONLY USED.

24. TRIALS FOR TRICUSPID VIV

25. TRANSCATHTER VALVE IMPLANTATION IN THE PULMONARY POSITION. FIRST PERFORMED IN 12 YR OLD BOY WITH DEGENERATION OF PROSTHETIC CONDUIT. CORONARY ANATOMY TO BE ASSESSED. MELODY OR ESV VALVE ARE COMMONLY USED.

26. CONCLUSION TREATMENT OF PURE AR WITH CONVENTIONAL DEVICES IS ASSOCIATED WITH LOW SUCCESS RATE OF 75%. TAVR OF BICUSPID VALVE IS ASSOCIATED WITH HIGHER INCIDENCE OF PARAVALVULAR LEAK. TAVR IS VALUABLE OPTION FOR VALVE DEGENERATION. MITRAL VIV AND VIR ARE CHARACTERISED BY GOOD EFFICACY IN REDUCING MR OR TREATING MS.

27. CONCLUSION TRICUSPID VIV IS EMERGING AS GOOD OPTION. TRICUSPID VIR IMPLANTATION IS LIMITED BY THE DESIGN OF TRICUSPID RING. MELODY VALVE IS PREFFERRED FOR PERCUTANEOUS PULMONARY VALVE IMPLANTATION.