Percutaneous Implantation of Aortic Valve Prostheses in Patients with Calcific Aortic Stenosis - Technical Advances

Percutaneous Implantation of Aortic Valve Prostheses in Patients with Calcific Aortic Stenosis - Technical Advances

Cribier Alain
Interventional Cardiology 2007
Published: October 2007
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Due to the ageing population and the consequent increased prevalence of aortic stenosis,1 the management of this disease in elderly patients, especially when associated with complex co-morbidities, is becoming an important issue for physicians. While surgical valve replacement remains the ‘gold standard’ treatment, operative mortality and morbidity increase with age and become significantly higher when pre-existing co-morbidities are present.2,3 As demonstrated by the EuroHeart Survey on Valvular Disease,4 as many as one-third of patients with symptomatic aortic stenosis are not undergoing surgery because of age, high-risk cardiac disease, other co-morbidities and/or simply lack of referral to surgery.5 However, with the development of transcatheter heart valve implantation the treatment of aortic stenosis for this subset of patients has entered a new era: with this technique, valves may be placed either through the femoral vessels, vein or artery (transfemoral), or through the apex of the left ventricle (transapical).

To date, two models of percutaneous aortic valve prosthesis have been used in investigational studies in elderly patients with excessive co-morbidities who have been deemed ineligible or very high-risk for surgical valve replacement: the balloon-expandable prosthesis from Edwards Lifesciences (first-generation: Cribier-Edwards valve; secondgeneration: Edwards-Sapien valve; Edwards Lifesciences Inc., Irvine, CA), first implanted in a human in 2002 by our group;6 and the selfexpandable CoreValve prosthesis (CoreValve Inc., Irvine, CA), which was first described as an alternative technique in 2005.

The balloon-expandable prosthesis consists of a tubular slotted stainlesssteel stent available in two sizes (23 and 26mm in diameter at full expansion) with an attached equine (first-generation) then bovine (second-generation) pericardial trileaflet valve. A sewn fabric cuff covers the left ventricular half of the prosthesis. A mechanical crimping device is utilised to compress the prosthesis onto a specially constructed valvuloplasty balloon catheter in order to reduce the balloon/valve assembly profile to make it compatible with a 22F (8mm external diameter) or 24F (9mm external diameter) sheath, depending on the diameter of the valve used. This prosthesis is delivered in the subcoronary position, anchored within the native calcified valve.

The CoreValve revalving system is a self-expanding prosthesis that uses a porcine bioprosthesis within a nitinol frame. There have been several device modifications since 2005, leading to a reduced sheath size from 24F to the current 18F device (third-generation). In contrast to the balloon-expandable prosthesis, anchoring with the self-expandable valve is achieved within the ascending aorta as well as within the native valve. Both prostheses have now been demonstrated to be effective, resulting in marked haemodynamic and clinical improvements and overcoming the numerous technical and clinical challenges encountered during the first clinical steps.

The balloon-expandable prosthesis was initially implanted on a compassionate basis in a population of elderly patients who had debilitating, life-threatening aortic stenosis with numerous co-morbidities; the challenging antegrade transeptal approach was used. After transeptal catheterisation, a stiff guidewire was advanced through the left atrium and the left ventricle and across the native aortic valve to the descending aorta, and externalised through the contra-lateral femoral artery. This guidewire offered an optimal support for advancing the prosthesis from the femoral vein to the aortic valve, but could exert traction on the anterior leaflet of the mitral valve with subsequent transient massive mitral regurgitation and haemodynamic collapse during the procedure. Even under optimal conditions, the management of this population of patients with severe aortic stenosis treated with a transcatheter heart valve represented a big challenge.

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