Evolving Concepts in Transcatheter Aortic Valve Implantation

Abstract

Part I of the present thesis is dedicated to implantation technique and the clinical performance of new valve prostheses. A satisfactory TAVI result not solely depends on patient characteristics, but also relies on proper valve positioning and final placement. Moreover, prosthetic design is an important determinant of implantation feasibility, efficacy and safety. In Chapter 2 we report on our two-step inflation technique for balloon-expandable valve implantation, which was introduced to enhance the precision of prosthesis placement. In Chapter 3 the feasibility, efficacy and safety of TAVI with a new self-expanding prosthesis for large aortic annuli is evaluated in an international multicenter study design. In Chapter 4 the clinical performance of the newest iteration of a balloon-expandable valve system, designed to reduce post-implantation aortic regurgitation, is compared to its predecessor by means of propensity-score matching. Part II of this thesis focuses on procedural outcomes. Institutional and operator experience have been shown to impact the outcome of many interventions. Improved procedural outcomes are further expected from technological advances and refined patient selection. In TAVI, results may additionally be influenced by anesthetic technique and the use of intraoperative adjunctive imaging. Mainly comprising elderly with multiple comorbidities, patients who undergo TAVI may well be at increased of postoperative delirium. In Chapter 5 we assess the value of adjunctive intracardiac echocardiography during fluoroscopy guided transfemoral TAVI under local anesthesia and conscious sedation, and report the outcomes achieved with this strategy. In Chapter 6 temporal trends in procedural outcomes are investigated in our single-center seven year TAVI experience, illustrating the impact of the learning curve and technological advances. In Chapter 7 we report on the incidence, predictive factors and impact of postoperative delirium after TAVI, a complication largely ignored by the interventional cardiology community so far.