Introduction

Transcatheter treatment of aortic valve (AV) disease continues to progress in device development and refinement, improvements in preprocedural planning, and refinements in procedural techniques to improve operative safety, efficiency, and outcomes. Due to these improvements along with patient preference for bioprosthetic aortic valve replacement and minimally invasive approaches, the number of transcatheter aortic valve replacements (TAVR) has surpassed the number of surgical aortic valve replacements (SAVR) performed annually in the United States.[1]Aortic stenosis (AS) is the predominant disease etiology treated with transcatheter devices; however, the treatment of aortic regurgitation (AR) and structural valve deterioration (SVD) of previously placed aortic prosthesis, either surgical or transcatheter aortic valve replacement, continues to evolve. Management of AV disease must be considered in regards to lifelong patient management including patient age, the presence of an ascending aortic aneurysm, considerations regarding anticoagulation, and other cardiac disease including mitral or tricuspid valvular disease and coronary artery disease.[2]

While native AS continues to be the most common AV disease treated with TAVR currently; transcatheter options for aortic regurgitation are under ongoing investigation.[3] The prevalence of AS increases with age and is the most common form of acquired degenerative valve disease in the US. The patient population treated with TAVR continues to expand from high risk, elderly patients to low risk, younger patients as outcomes from low risk TAVR clinical trials, PARTNER 3 and EVOLUT, become available. [4], [5] The safety profile of TAVR along with patient preference has led to a continuing increase in the annual volume of TAVR procedures, which has surpassed the volume of isolated surgical aortic valve replacement.[1] The increasing rate of surgical TAVR explant must also be considered along with the options for treatment of SVD of both surgical and transcatheter bioprosthetic valves.[6][7]

Transfemoral approach for TAVR is the most common route for valve delivery and has superior outcomes to alternative access options. Transfemoral (TF) TAVR is feasible in over 95% of patients with evolving device and sheath technology. Leaflet augmentation has been an important component in procedural advancements in TAVR to reduce risk for coronary occlusion, particularly in valve-in-valve (ViV) procedures. Currently, commercially available TAVR devices are either balloon expandable valves (BEV) or self-expanding valves (SEV) and anchor in calcium at the aortic annulus.