Commentary: More haste, less speed.

Michele Di Mauro, MD, PhD (left), and Luca Paolo Weltert, MD (right).

If we really want the procedure to be consistent for our patient, careful thought should be given to optimizing implanting criteria.

See Article page 87.

The widespread adoption of the transcatheter aortic valve implantation procedure has had major impact on the cardiovascular practice of the last years, and for good reasons The possibility of replacing a failed valve on the awake patient, with no extracorporeal circulation and no scar at all, is the holy grail of structural heart disease therapy.1, 2, 3 However, this forward acceleration heavily relies on technology, rather than technique as has traditionally happened in the past, where the incremental steps from technologic advancements played an evolutionary role in established sequence rather than being a total revolution.

The initial concerns of rapid and devastating flaw are now a thing of the past, and the technique has gained a solid reputation. The literature, however, is becoming populated by reports of failing devices,5, 6, 7 both at midterm (so-called structural valve deterioration) and at the early stage, such as the account in this edition of the Journal by Park and colleagues. They make an important statement in commenting on their case report: as valves become thinner to accommodate smaller deployment sheath sizes, significantly higher stress at the hinge is demonstrated by many studies. On top of this, dilatation by balloon valvuloplasty poses high stress on the leaflet and hinges as well.

This report and others should induce us to consider carefully the ineludible constraints of the methodology: the dimension of the artery that serves as introduction, the dimension of the valve at its crimped stage, and the impact of implantation trauma on the valve tissue, in terms both of acute damage and accelerated calcification. These “pillars” define the stage where the act is played and are related to physical dimensions that the actual technology has not overcome. Yet, if we really want the procedure to be consistent for our patients, careful thought about implantation criteria should probably be optimized and tailored to the individual, up to the point of having to tell some patients that they are not suitable for a safe durable implant.