- There are three interventional options for severe symptomatic AS
- The choice for intervention must be based on careful individual evaluation of technical suitability and weighing of risks and benefits of each modality
Interventiom
Description
Indications
Surgical Valve Replacement
- Remains the gold-standard intervention for severe AS
- Prosthetic valves can be mechanical or tissue
- Mechanical valves offer increased lifespan and durability but carry thrombosis risk requiring lifelong anticoagulation
- Tissue valves (allograft, homograft or autograft) offer shorter lifespan but anticoagulation not required
- Significant proportion of patients are denied surgical valve replacement due to high surgical risk
- Recommended in patients at low surgical risk (EuroSCORE II <4% and no other risk factors)
Transcatheter Aortic Valve Implantation (TAVI)
- A minimally invasive procedure that avoids the need for open cardiac surgery, sternotomy and cardiopulmonary bypass
- The aortic valve ring is dilated using a balloon catheter over a guidewire before a new prosthetic valve is manipulated into position inside the existing aortic valve
- Access is most commonly transluminal (femoral or subclavian) but is occasionally via mini-thoracotomy and puncture of the left ventricle (transapical)
- TAVI may be done with the patient under general anaesthesia or more commonly under local anaesthesia with or without sedation
- Recent evidence suggests TAVI offers improved survival compared to BAV and comparable results surgical AVR in high-risk patients
- Recommended in patients who are not suitable for SAVR as assessed by the multidisciplinary team Heart Team (EuroSCORE II >4% or other risk factors)
Balloon Valvuloplasty (BAV)
- Involves the passage of a guidewire and balloon across the stenotic valve and repeated inflation to dilate the valve
- Can be accessed via the femoral artery (retrograde approach) or the femoral vein and transeptal puncture (antegrade approach)
- Carries a high restenosis rate and poor long-term survival preventing its role as definitive treatment
- In carefully selected patients, balloon valvuloplasty can be used as a:
- Bridge to surgery for patients who are hemodynamically unstable or require urgent major non-cardiac surgery
- Palliatiative procedure in patients with multiple comorbidities who are poor operative candidates