Transcatheter Aortic Valve Implantation: towards safer and leaner procedures

Abstract

The introduction of transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of patients with severe aortic stenosis by providing a minimally invasive alternative to open-heart surgery. Initially developed for patients who were considered unsuitable for open-heart surgery, TAVI has become the preferred treatment for patients aged 75 years and older, regardless of their surgical risk profile. The indication for TAVI is expected to expand further in the coming years. The first part of this thesis focuses on the incidence and temporal trends of complications and their impact on survival, using data from more than 25,000 patients. The results show that severe complications requiring emergency open-heart surgery have become rare. In addition, the risk of major bleeding has declined substantially, although it still affects a considerable proportion of patients. In contrast, the incidence of stroke following TAVI has remained largely unchanged over the years. The second part of this thesis focuses on patients with both severe aortic stenosis and coronary artery disease. For many years, these patients underwent a routine percutaneous coronary intervention (PCI) before TAVI. However, the results of the randomized PRO-TAVI trial demonstrate that it is safe to defer this routine PCI. Patients who did not undergo PCI before TAVI had comparable clinical outcomes, while the risk of major bleeding complications was significantly lower. Moreover, only a small proportion of patients required PCI after TAVI, and these procedures could generally be performed safely without technical difficulties. The optimal treatment of patients with severe aortic valve stenosis, with or without concomitant coronary artery disease, requires a personalized approach. The findings of this thesis contribute to a more streamlined and evidence-based treatment strategy for this growing patient population.