Transcatheter resection of the native aortic valve prior to endovalve implantation - A rational approach to reduce TAVI-induced complications.

Complications due to compression of diseased native aortic leaflets between the endovalve and the aortic wall after transcatheter aortic valve implantation (TAVI) have been well described. Four factors have encouraged the evaluation of TAVI in lower-risk populations with aortic stenosis: rapid improvements in TAVI technology, increasing experience in recent years, the encouraging results obtained in multi-center registries and, most importantly, the results from the high-risk cohort of the PARTNER trial. Indeed, some preliminary results of TAVI in intermediate-risk patients with severe aortic stenosis have been promising (1). There are already reports of TAVI in low-risk patient series. Lange (2) reported a series of 420 patients who underwent TAVI using the CoreValve (Medtronic, Inc., Minneapolis, Minnesota) or Edwards SAPIEN (Edwards Lifesciences, Irvine, California) valve. Patients undergoing TAVI in the first quartile had significantly higher logistic EuroSCORES than those in the second, third, or fourth quartiles (Q1: 25.4±16% vs. Q2: 18.8±10% vs. Q3: 18.3±11% vs. Q4: 17.8±12%, analysis of variance P<0.001). There were no significant differences in mortality rate observed between Q1 and Q4 after adjustment for baseline characteristics at 30-day and 6-month follow-up (30-day mortality rate adjusted HR: 0.29; 95% CI: 0.08 to 1.08; P=0.07; 6-month adjusted mortality rate HR: 0.67; 95% CI: 0.25 to 1.77; P=0.42). They conclude that the results of the study demonstrate an important paradigm shift toward the selection of lower surgical risk patients for TAVI. Significantly better clinical outcomes can be expected in lower than in higher surgical risk patients undergoing TAVI. As TAVI becomes more routine widely available, operators may be tempted to implant the device in younger patients with fewer comorbidities. In this paper we will demonstrate the necessity of resecting the native aortic valve prior to TAVI especially in young, low-risk patients. In particular, we will focus on known complications of TAVI and how native aortic valve resection may decrease the occurrence of these complications.