Transcatheter aortic valve implantation (TAVI) in patients with aortic regurgitation.

Transcatheter aortic valve implantation (TAVI) has become the standard of care for elderly high-risk patients presenting severe and symptomatic aortic valve stenosis, while surgical aortic valve replacement (sAVR) is still considered as the treatment of choice for younger patients and patients with low and intermediate risk profiles (1,2). With more than 100,000 implants worldwide, TAVI has changed the paradigm in the treatment of aortic valve stenosis. The principle concept of TAVI is based on implanting a balloonor self-expandable transcatheter heart valve into the calcified native aortic annulus (3). Therefore, a certain amount of aortic annulus and/or valve calcification is presumably essential to anchor the valvemounted stent-frame into the annulus. This follows from the fact that, pure, severe aortic regurgitation has been considered as a relative contraindication to TAVI due to the absence of aortic calcification. This is also reflected by the instructions for use of all commercial TAVI systems. On the other hand, there is clearly an unmet clinical need for TAVI as high-risk patients frequently present with a combined aortic valve disease with predominant regurgitation without a reasonable amount of calcium or even pure aortic regurgitation without any aortic valve calcification. Up to now, those patients were mostly treated by sAVR. More recent experiences with TAVI in patients with aortic regurgitation has been reported in several case reports and small clinical studies. The first successful cases were reported as ‘off-label’ procedures by using the CoreValveTM (Medtronic, Minneapolis, Minnesota, USA) as well as the Edwards Sapien THV system (Edwards Lifesciences LLC, Irvine, CA, USA) (4-6). Since then, the only approved valve system to be used in pure aortic regurgitation is the JenaValveTM prosthesis (JenaValve Technology GmbH, Munich, Germany) (7,8). The J-valveTM system (JC Medical, Inc. Burlingame, CA, USA and Suzhou, China), a recently introduced new, also selfexpandable TAVI-system has also been used in pure aortic regurgitation (9) and just recently, the LotusTM valve system (Boston Scientific, Marlborough, MA, USA) was reported to be used successfully for treatment of patients with pure aortic regurgitation. Another interesting concept of a selfexpandable transcatheter valve, the Symetis ACURATE TATM device (Symetis S.A., Ecublens, Switzerland) has been introduced firstly for pure aortic regurgitation by our Essen TAVI group (10), being the largest single-center study published so far. In the following, a case example of a high-risk patient suffering from symptomatic pure aortic regurgitation undergoing a TAVI procedure is presented. This procedure was performed as a Live-case during the Aortic Live 2 Meeting in 2014 at the West-German Heart Center Essen.