Conclusion
From the wealth of registries and trials scrutinising its performance, TAVI emerges as a viable and rapidly established option, both when compared with medical treatment in inoperable patients and when compared with conventional surgical treatment in high-risk patients. It has revolutionised the treatment of high-risk patients with severe calcific aortic stenosis, and results continue to improve as operator experience grows and technology develops.
Long-term results in well-selected patients are excellent, although choosing the right patient is vital. From the trials mentioned, the independent predictors of outcome are BMI, COPD, post-TAVI AR, porcelain aorta, liver disease, AF, renal disease and impaired LVEF, many of which are not accounted for within currently available risk stratification tools. A more recent publication assessing predictors of 6-month poor clinical outcome after TAVI has shown AF, severe baseline pulmonary hypertension and right ventricular dysfunction to be associated with poor outcome, and baseline AR to be protective.21 While TAVI is an excellent option, it is important to consider which patients are least likely to benefit, including those with a euroSCORE >40, severe left or right ventricular systolic dysfunction, severe respiratory disease and restricted mobility.
Trans-femoral access is associated with improved overall survival, although it is clear that the cohort of patients treated via an alternative route already have a more adverse risk profile. Advances in technology will hopefully address areas of concern such as paravalvular AR and pacing requirements.
Current risk scores have good discrimination (low versus high risk), but poor calibration (predicted versus observed risk)22 and we need more rigorous risk stratification tools. However, the role of the heart team remains central in optimal patient selection. Nearly 12 years since the first procedure, TAVI is flourishing, and with ongoing development, will continue to do so.