Transcatheter Aortic Valve Replacement/trends

ABCIC

Case Report

Dysfunctional Mitral Bioprosthesis Treated using Transapical Approach with Inovare Transcatheter Valve: A New Alternative to Conventional Surgery

Williams Roberto Lata Gacho et al. Jaime Paula Pessoa Linhares Filho Henrique Barbosa Ribeiro Roney Orismar Sampaio … José Onório Almeida Palma Fonseca Márcio Silva Miguel Lima

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Viewpoint

Treatment of Aortic Stenosis in Elderly Individuals in Brazil: How Long Can We Wait?

Marcelo Antônio Cartaxo Queiroga Lopes et al. Bruno Ramos Nascimento Gláucia Maria Moraes de Oliveira

The growing life expectancy of the population is increasing the occurrence of diseases affecting the elderly age group, notably the non-rheumatic degenerative valvular diseases and, in particular, aortic stenosis, whose prevalence in elderly individuals older than 75 years has been estimated at 3 to 5%. This is the most common valvular heart disease among elderly individuals, and its severe form is associated with high morbidity and mortality. The life expectancy of patients with aortic stenosis presenting with heart failure and rhythm disturbances is estimated to be less than 2 years. The standard treatment for this disease is cardiac surgery with replacement of the aortic valve by a prosthesis. However, due to high surgical risk, especially in very elderly patients with associated comorbidities, cardiac surgery is contraindicated in about 30% of the cases or is performed with high morbidity and mortality rates according to preoperative scores. For these critically ill patients, a new, less invasive technique consisting of transcatheter aortic valve implantation (TAVI) of a bioprosthesis has been considered the therapeutic option of choice, initially tested in patients at very high surgical risk, but currently with evidence of noninferiority compared to open surgery in lower-risk individuals.^, The first TAVI procedure in the world was performed in France in 2002 by Professor Alain Cribier, and the method was pioneered in Brazil in 2008. Since then, a considerable number of patients has been treated. However, despite robust evidence of safety and efficacy, this therapy has still not been incorporated into the supplemental or public health care systems (Sistema Único de Saúde [SUS]) in the country.

Despite the fact that TAVI has already been evaluated and accepted in the health care systems of several countries with evidence of cost-effectiveness even in individuals at intermediate operative risk, the Ministry of Health, based on a position stand from the National Commission for Incorporation of Technologies in the SUS (Conitec), established in 2013, in response to a request by the Brazilian Society for Hemodynamics and of Interventional Cardiology (SBHCI) acting as the petitioner, considered that there was no convenience in incorporating this therapy in Brazil. Conitec, at the time, based on the opinion of a reviewer and disregarding the opinion of prestigious national universities presented in a public consultation on the subject, recommended against the incorporation of the procedure, justifying this decision on three points: a) TAVI would not be a safe and effective procedure due to an allegedly high incidence of stroke within the first 30 days after the procedure, b) the budgetary impact of incorporating TAVI into the SUS would approach 1 billion reais per year, and c) methodological inaccuracies could have affected the economic model presented by the petitioner and the PARTNER B study, which served as the main background for the incorporation of this procedure by all health technology assessment agencies in the world that have requested the incorporation of this technology.

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Editorial

Impact of Transcatheter Aortic Valve Implantation on Kidney Function: the “Renovalvular” Interaction in Aortic Stenosis

Antonio de Santis

The advent of renal congestion in heart failure was first described by Frédéric Justin Collet (1870-1966), a French pathologist who found the notion of passive renal congestion related to heart dysfunction, creating the revealing term “rein cardiaque” in the early 1900s. The term cardiorenal syndrome emerged from a 2004 National Heart, Lung, and Blood Institute Working GrouP conference evaluating the complex interactions between the heart and kidney. The main pathophysiological mechanisms related to this condition are increased central venous and intra-abdominal pressures; reduced cardiac output and cardiac index; neurohormonal dysregulation; oxidative stress and inflammatory mediators. Degenerative aortic stenosis (AS) represents one of the most prevalent valvular heart diseases and an important cause of heart failure, with a strong correlation with aging process. The combination of atherosclerosis, biomineralization and oxidative stress leads to calcium deposition within the valve leaflets. The “renovalvular” interaction in AS may represent a two-way path, from a pathophysiological perspective. In one way, AS may impair kidney function by arterial hypoperfusion and systemic venous congestion. On the other way, chronic kidney disease (CKD) is also an important risk factor for AS, due to the massive and aggressive calcification of the leaflets, mainly imposed by imbalances in the calcium and phosphorus homeostasis.

For patients with AS undergoing conventional surgical aortic valve replacement (AVR), there is an increase in complication rates such as major bleeding and reoperation when comparing patients with moderately reduced kidney function (estimated glomerular filtration rate [eGFR] between 30-60 ml/min/1.73 m) versus those without kidney disease. Mortality after surgical AVR also increases with worsening GFR.

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Dysfunctional Mitral Bioprosthesis Treated using Transapical Approach with Inovare Transcatheter Valve: A New Alternative to Conventional Surgery

Treatment of Aortic Stenosis in Elderly Individuals in Brazil: How Long Can We Wait?

Impact of Transcatheter Aortic Valve Implantation on Kidney Function: the “Renovalvular” Interaction in Aortic Stenosis

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