Current Status, Challenges and Future Directions in Aortic Valve Replacement

Dear Colleagues,

The treatment of aortic valve disease remains dynamic, and the role of the heart team is globally recognized to identify the best therapeutic strategy for each patient. Since the introduction of TAVI in 2002 by Alain Cribier, the emerging role of transcatheter techniques has been documented by the literature and reflected in clinical practice which, for prohibitive or high-surgical-risk patients, is commonly often the proposed and selected solution even in younger and lower-risk patients.

Having said that, the excellent short- and long-term results of traditional surgery make the latest advances still up to date and attractive for patients. Moreover, the surgical approach has changed over the years, and several different approaches have been proposed to minimize the invasiveness of the standard sternotomy approach, such as upper ministernotomy and minithoracotomy. The latest surgical innovation, the endoscopic approach (including robotic surgery), has also emerged in recent years. Also, new technologies in biological tissue for aortic valve prosthesis have been developed, together with rapid deployment and suture-less prostheses to minimize invasiveness and surgical time with promising results. To reduce the impact of patient prosthesis mismatch, root enlargement techniques are also increasingly evolving to ensure a longer life free from reoperation and SVD.

The Ross procedure is also re-emerging in experienced centers and selected patients and, even if technically more complex, for some surgeons, it could be considered the “old but gold” solution to the emerging issue of a long-term and definitive solution in lifetime management in terms of a long-term prospective view.

Lifetime management of aortic valve disease has increasingly become a real challenge for clinicians. The TAVI as a valve in a valve (ViV) treatment for structural valve degeneration could be found to be an attractive solution again for the present day; however, the results are often suboptimal and new solutions have been adopted instead. 

Parallel to ViV, an emerging issue is the surgical solution to a degenerated TAVI; an increasing number of publications focused on the hot topic of TAVI explantation have been reported, but even more often complex surgeries with high-risk morbidity and mortality are required. Also, TAVI in TAVI is an emerging issue.

The best strategy for the treatment of aortic valve disease still remains tailored to each patient, and multidisciplinary evaluation in order to identify the lifetime benefits and risks ratio is the only way to go. 

To date, some points of debate still remain on treatment aortic valve disease, such as the following:

• Selection of surgical prosthesis: differences in biological prosthesis and the actual role of mechanical prosthesis.
• The importance of the heart team (HT) and the fundamental role of the on-site cardiac surgery stand for emergencies and complications during the TAVI procedure, requiring sternotomy or open-heart surgery.
• Benefits of minimally invasive and robotic aortic valve
• Alternative access and solutions for TAVI whenever trans-femoral access is complex or prohibitive.
• ViV procedures: patients’ selection, strategies to optimize results, and clinical follow-up.
• Explant TAVI: indication and surgical results; would you make the same choice again?
• Ross procedure: surgical indications, and pro, cons, and real possibility of using the application nowadays.
• Root enlargement techniques and the role of patient–prosthesis mismatch.
• Lifetime management strategy, an ethical role for surgeons.

The aim of the present Special Issue is to present the latest evidence and new findings regarding different approaches in cases of surgical or transcatheter aortic valve replacement; manuscripts within this area of research are welcome to be submitted.

Moreover, we encourage all submitted articles to address the issues listed above and also provide a comparison between the results of surgical and transcatheter techniques.

Dr. Guglielmo Saitto
Dr. Giovanni Alfonso Chiariello
Guest Editors

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• aortic valve
• aortic valve replacement
• minimally invasive surgery
• robotic surgery
• TAVI
• ross operation
• root enlargement techniques
• heart team
• lifetime management