Interview: TAVI in Younger, Lower-risk Patients

Dr Rui Campante Teles
Interventional Cardiologist and Head of the Structural Heart Disease Programme, Lisbon, Portugal

1. What are the key considerations when evaluating a younger, lower-risk patient for TAVI rather than surgical AVR?

At this stage, we have scientific evidence that allows us to consider TAVI as an alternative to surgical therapy, which has traditionally been the most common treatment. Based on evidence from trials such as NOTION, we understand that we can achieve very good results in these patients.

The main question is whether there are any patient-specific features that increase the risk of TAVI. In younger, low-risk patients, we try to establish whether the anatomy is favourable for TAVI. If it is, I believe it is an acceptable first-line treatment according to the available evidence.

However, if there are adverse anatomical features, such as bicuspid anatomy that is very calcified, elliptical or eccentric, this may be a reason to refer the patient for surgery instead.

2. How should coronary access be factored into procedural planning in this population?

Because these patients are expected to live longer, we have to be extremely careful regarding coronary disease. Although many patients may not have coronary artery disease at the time of treatment, over 10 or 15 years some degree of coronary disease may develop.

For that reason, it is critical to understand the anatomy. Even if a patient does not have coronary artery disease, we need to be sure we will be able to access the coronaries in the future, allowing us to perform coronary angiography and, if necessary, PCI.

This means selecting devices that allow for that approach. We tend to choose valves that are either short-frame devices or, if they have longer frames, have large cells. Today we have several devices that can provide this concept.

Coronary access is always in our minds, but we now have several solutions that can provide good access in the long term.


3. What does lifetime management look like in practice for a patient who receives TAVI in their 60s?

The most important consideration is valve durability.

There are several goals we need to achieve, all of which remain extremely important in younger patients. We need good coronary access, as mentioned previously. We also need good valve expansion to avoid pinwheeling and thrombotic processes within the valve.

We must ensure the valve is properly expanded and that there is no paravalvular leak, as this can become problematic in the long term. We also need to avoid permanent pacemaker implantation whenever possible.

In addition, we need to select the proper device, not only with respect to coronary access, but also valve haemodynamics and valve performance. If the valve is too small for the patient, this may impact long-term outcomes.

For me, these considerations are critical when thinking about younger patients.


4. How should heart teams approach the prospect of future valve-in-valve procedures when selecting the index valve?

The index valve is critical, not only for achieving good acute results in terms of haemodynamics and avoiding paravalvular leak, but also because of its impact on long-term durability.

Several devices are available that can provide long-term durability, but the choice depends on the patient's anatomy.

For example, in patients with a smaller annulus, a supra-annular device may allow us to achieve better haemodynamics. In heavily calcified anatomies, we need valves that can achieve adequate expansion and provide sufficient radial force.

Anatomy is therefore key to the future durability of the valve. Device selection and valve selection are critical factors alongside sizing.

5. What are your take-home messages for heart teams expanding their TAVI programme into lower-risk patients?

Today, we can say that TAVI is an option for many younger, lower-risk patients.

However, we have to remain cautious in patients who present with adverse bicuspid disease. In those patients, surgery remains a very good option.

It is important to involve the patient in the decision-making process so that they understand all available possibilities.

What is new compared with a few years ago is that we now have evidence showing that TAVI is a very good first-line therapy for younger patients.