Non-invasive high-energy ultrasound: alternative treatment before transcatheter aortic valve implantation?

Degenerative aortic valve stenosis is characterised by thick calcium nodules on the valve leaflets, responsible for incomplete expansion and aortic regurgitation via paravalvular leaks in the early transcatheter aortic valve implantation (TAVI) experience. 1 Davidson LJ Davidson CJ Transcatheter treatment of valvular heart disease: a review. JAMA. 2021; 325: 2480-2494 Crossref PubMed Scopus (43) Google Scholar Fortunately, progress in valve technology has greatly limited these drawbacks of the early TAVI experience, with sufficient expansion achieved using appropriately sized valves and optimised valve positioning. 2 Barbato E Gallinoro E Abdel-Wahab M et al. Management strategies for heavily calcified coronary stenoses: an EAPCI clinical consensus statement in collaboration with the EURO4C-PCR group. Eur Heart J. 2023; (published online May 19.)https://doi.org/10.1093/eurheartj/ehad342 Crossref Google Scholar , 3 Kereiakes DJ Di Mario C Riley RF et al. Intravascular lithotripsy for treatment of calcified coronary lesions: patient-level pooled analysis of the Disrupt CAD studies. JACC Cardiovasc Interv. 2021; 14: 1337-1348 Crossref PubMed Scopus (53) Google Scholar Newly crafted skirts on the ventricular side of the valve have largely succeeded in fitting the gaps left around the irregular native valve calcifications. 4 Leone PP Scotti A Ho EC et al. Prosthesis tailoring for patients undergoing transcatheter aortic valve implantation. J Clin Med. 2023; 12: 338 Crossref PubMed Scopus (4) Google Scholar In a limited number of cases, extreme leaflet calcification, calcium in the raphe of bicuspid valves, or calcium extending into the left ventricle outflow tract might still offer insurmountable obstacles to optimal TAVI treatment. A safe and effective technique to cause controlled cracks in the calcium could overcome these residual limitations. In addition, many patients are still refused TAVI based on frailty or comorbidities reducing life expectancy, and are referred for palliative treatment that includes balloon aortic valvuloplasty (BAV). However, despite the increased operator experience with balloon size selected based on CT angiography and a stable balloon position with high-frequency pacing, the results of BAV remain highly unpredictable and often disappointing. 5 Cribier A Savin T Saoudi N Rocha P Berland J Letac B Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement?. Lancet. 1986; 1: 63-67 Summary PubMed Google Scholar Calcium modification before valvuloplasty has the potential to improve the outcome of BAV. Another potential application for calcium modification is early treatment of moderate aortic valve stenosis in order to defer surgical or transcatheter aortic valve replacement. A safe and effective non-invasive calcium modification treatment could reduce time pressure and avoid premature implantation of biological valves with a predictably short lifetime, thus reducing the need to redo valve-in-valve procedures. Treatment of severe symptomatic aortic valve stenosis using non-invasive ultrasound therapy: a cohort studyThis novel, non-invasive ultrasound therapy for calcified aortic stenosis proved to be safe and feasible. Full-Text PDF