BACKGROUND:

Transcatheter aortic valve replacement (TAVR) has emerged as a standard therapy for patients (pts) with severe symptomatic aortic stenosis (AS). Its indications have expanded from high-surgical to low-surgical risk pts. However, some pts may be not eligible for the procedure due to clinical and/or anatomic reasons.

OBJECTIVE:

We aimed to investigate the clinical and anatomical characteristics of pts judged ineligible for TAVR and outcomes in this population.

METHODS:

Observational, single-center experience. All consecutive pts with AS and potential candidates for TAVR presented in Heart Team meetings were selected. Pts not referred for TAVR were followed since the day they were considered ineligible for the procedure until last clinical follow-up.

RESULTS:

From September 2020 to February 2024, 313 pts were evaluated for a potential TAVR indication, and 38 (12%) were considered ineligible. Mean age was 74.8±6.65 years, 52% were male, and mean STS score of 4.42±3.48% (63% had low surgical risk as assessed by STS score < 4%). Most pts (92%) were symptomatic with 47% in NYHA class III-IV. Mean aortic valve area was 0.64±0.15 cm2 and mean LV ejection fraction was 50%±15%; Fifteen percent of pts had right ventricular dysfunction. In terms of anatomical characteristics, 5 (13%) pts had a low coronary take-off and 39% had iliofemoral diameters <5.5 or calcifications. Moreover, 42% of pts had associated coronary artery disease. The most common reason for being defined as ineligible was unfavorable vascular access (36%), followed by a challenged valve anatomy (31%) - mainly due to severe annular and/or left-ventricular outflow tract calcifications. Half of pts were kept in medical treatment or were treated with palliative care. Surgery was offered to 39% of the pts. Moreover, 10% of the pts rejected the indication of TAVR. After a median follow-up of four months, death occurred in 21% of ineligible pts for TAVR and in 25% when surgery wasn`t done as a treatment.

CONCLUSION:

In accordance with previous findings, our series showed that severe AS was a deadly disease, with > 20% of short-term mortality if left untreated. A non-negligible percentage of pts are not eligible for TAVR, mostly due to limitations regarding vascular anatomy and risks associated with calcifications on the aortic complex. The use of alternative vascular access and/or the development of lower profile delivery and safer TAVR systems are still needed in a broader population.