New approach for aortic valve replacement is feasible

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According to a report in The Journal of Thoracic and Cardiovascular Surgery, totally endoscopic aortic valve replacement (TEAVR) is technically feasible. Lead author of the report Marco Vola (Cardiovascular Surgery Unit, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France) talks to Cardiovascular News about TEAVR and its potential role in the management of patients with aortic stenosis. 

What is “TEAVR”?

It is an aortic valve replacement procedure performed with a surgical bioprosthetic aortic valve through an exclusively thoracoscopic approach.


In your report, you state that the development of sutureless bioprosthesis valves have made TEAVR feasible. Can you explain why this is?

Sutureless nitinol stented valves are an essential element of TEAVR because they can be compressed and inserted into the thorax of the patient through surgical trocars and decompressed into the aortic root. “Conventional” stented bioprostheses cannot be compressed and therefore, need to be inserted with a short second or third space thoracotomy with ribs spreading or a partial sternotomy.


Y
our report details the use of TEAVR in two patients with aortic stenosis. What were your main observations of the procedure in these patients?

We found that, in terms of technical observations, the deployment and positioning of the valve were not the most technically and time demanding parts of the procedure—the most time consuming parts were the aortic valve and annulus decalcification and aortic closure. Also, we found that the patients did well after the procedure and both of them were able to be discharged seven days afterwards. However, we are still evaluating the technical feasibility of TEAVR; therefore, it is too soon to make conclusions about the potential clinical benefits of thoracoscopic aortic valve surgery.


Which patients do you think could benefit from this procedure?

The aim of this new approach is to minimise the chest trauma associated with surgical aortic valve replacement. Therefore with TEAVR, patients—providing that they are not at high risk for surgery—can receive the benefits of surgical aortic valve replacement, which is complete removal of the underlying pathology (the aortic calcified valve) as well as aortic valve replacement, without having to have their chest opened. TEAVR may be the future minimally invasive, but radical, treatment of aortic stenosis in intermediate-risk patients.

What future work is needed before TEAVR can be used in clinical practice?

Before we can see real effectiveness with the technique, we need to be able to perform an aortic valve with a “close chest” technique and with cross clamping times that are not longer than with the sternotomy approach; for that, we need second-generation sutureless valves to be developed. Development of such devices would answer, beyond a faster delivery into the aortic root, the further challenges that we have with the current devices—for example, we need valves that have a good ratio of compression to fit thinner trocars and we need ones that are designed to be easily “renewed” with a valve-in-valve procedure so as to create the possibility of using TEAVR to treat younger patients with a bioprosthetic option and most of those still receiving a mechanical valve and the consequent anticoagulating therapy.

However, beyond the development of valves specifically designed for TEAVR, it is necessary to make the endoscopic aortic valve decalcification, sizing, and aortic closure easier during the approach; again, dedicated devices are needed to reduce the procedure cross clamping times, and enhance reproducibility with a simplified procedure not relying on subjective tricks and tips.

If all of those conditions are fulfilled, TEAVR could become a more reproducible procedure and be possibly considered as an intermediate solution between transcatheter aortic valve implantation (TAVI) and open surgical aortic valve replacement.