Challenges and future opportunities for transcatheter aortic valve therapy.
BACKGROUND
Transcatheter aortic valve replacement (TAVR) is a novel less-invasive therapy for high-risk patients with severe aortic stenosis (AS). Despite the impressive clinical growth of TAVR, there are many challenges as well as future opportunities.


RESULTS
The heart valve team serves as the central vehicle for determining appropriate case selection. Considerations which impact clinical therapy decisions include frailty assessments and defining clinical "futility". There are many controversial procedural issues; choice of vascular access site, valve sizing, adjunctive imaging, and post-dilatation strategies. Complications associated with TAVR (strokes, vascular and bleeding events, para-valvular regurgitation, and conduction abnormalities) must be improved and will require procedural and/or technology enhancements. TAVR site training mandates a rigorous commitment to established society and sponsor guidelines. In the future, TAVR clinical indications should extend to bioprosthetic valve failure, intermediate risk patients, and other clinical scenarios, based upon well conducted clinical trials. New TAVR systems have been developed which should further optimize clinical outcomes, by reducing device profile, providing retrievable features, and preventing para-valvular regurgitation. Other accessory devices, such as cerebral protection to prevent strokes, are also being developed and evaluated in clinical studies.


CONCLUSIONS
TAVR is a worthwhile addition to the armamentarium of therapies for patients with AS. Current limitations are important to recognize and future opportunities to improve clinical outcomes are being explored.
Center for Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY. Electronic address: ml2398@columbia.edu.
Martin B
MB
Leon
Center for Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY.
Hemal
H
Gada
Lenox Hill Heart & Vascular Institute of New York, Lennox Hill Hospital, North Shore - LIJ Health Care System, Manhasset, NY.
Gregory P
GP
Fontana
D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000639:trends*; D004059:Diffusion of Innovation; D005544:Forecasting; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000639:trends*; D006801:Humans; D010043:Outcome and Process Assessment, Health Care / Q000639:trends*; D018579:Patient Selection; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
Aortic stenosis; Aortic valve replacement; Transcatheter aortic valve replacement