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Aortic valve: The new challenge for interventional cardiology!

Treatment of aortic valve disease remains reserved for Surgery. This surgery commands some inevitable risks specifically in the elder population, which are sometimes excessive. Aortic stenosis is typically a disease where the frequency increases with age, and where the Cardiologist is frequently confronted to doing nothing, medical treatment, or too much, intervention! At the end of the 1980’s, balloon valvuloplasty represented a big hope for aortic stenosis in the elderly patient: increase the aortic valve area without surgery [1]! The dream fades away with the recurrence of the restriction in 3 months! At the opposite, the balloon treatment of the Mitral Stenosis holds with time and persists the treatment of choice in most cases. Balloon dilation does not seem to be the solution for restriction after biologic aortic valve replacement where fibrosis and calcification are the main pathologic findings. Cracking this type of restriction will create rupture or at least major dysfunction of one leaflet with a major consequence: aortic regurgitation unbearable for some hypertrophic left ventricle [2]. Percutaneous valve implantation may represent the solution for such disease, either the native aortic valve stenosis or the stenotic bioprosthesis [3]. Alain Cribier and his group have reported the first implantations in end-stage patients with severe aortic valve stenosis not amenable to surgical valve replacement with immediate and mid term satisfactory valve function and early clinical improvement [4]. The challenges of this percutaneous implantation are the exact delivery, timing and location as much as flow centering and anchorage and the delivery itself anterograde or retrograde. Degeneration of bioprosthesis is inevitable and this elder population may need a second intervention years after the first one where their general condition will be more at risk for redo-surgery. This population may represent the ideal technical indication for “redo-valve implantation” but this time percutaneously. The annulus ring diameter and orientation will be well known, the ring will help for the anchoring and the remaining leaflets may sealed the new valve preventing leaking.