Background: In view of the rising global burden of severe symptomatic aortic stenosis, its early recognition and treatment is key. Although patients with classical low‐flow, low‐gradient (C‐LFLG) aortic stenosis have higher rates of death after transcatheter aortic valve implantation (TAVI) when compared with patients with high‐gradient (HG) aortic stenosis, there is conflicting evidence on the death rate in patients with severe paradoxical low‐flow, low‐gradient (P‐LFLG) aortic stenosis. Therefore, we aimed to compare outcomes in real‐world patients with severe HG, C‐LFLG, and P‐LFLG aortic stenosis undergoing TAVI. Methods and Results: Clinical outcomes up to 5 years were addressed in the 3 groups of patients enrolled in the prospective, national, multicenter SwissTAVI registry. A total of 8914 patients undergoing TAVI at 15 heart valve centers in Switzerland were analyzed for the purpose of this study. We observed a significant difference in time to death at 1 year after TAVI, with the lowest observed in HG (8.8%) aortic stenosis, followed by P‐LFLG (11.5%; hazard ratio [HR], 1.35 [95% CI, 1.16–1.56]; P <0.001) and C‐LFLG (19.8%; HR, 1.93 [95% CI, 1.64–2.26]; P <0.001) aortic stenosis. Cardiovascular death showed similar differences between the groups. At 5 years, the all‐cause death rate was 44.4% in HG, 52.1% in P‐LFLG (HR, 1.35 [95% CI, 1.23–1.48]; P <0.001), and 62.8% in C‐LFLG aortic stenosis (HR, 1.7 [95% CI, 1.54–1.88]; P <0.001). Conclusions: Up to 5 years after TAVI, patients with P‐LFLG have higher death rates than patients with HG aortic stenosis but lower death rates than patients with C‐LFLG aortic stenosis.

Although transcatheter aortic valve replacement was originally fulfilling an unmet clinical need in the elderly population suffering from tricuspid aortic valve stenosis, its use has been progressively expanded to other groups of patients. In this review, we will focus on pure native aortic valve regurgitation, which is in most cases a degenerative disease and, therefore frequently diagnosed in elderly patients with comorbidities. Symptoms tend to appear late in the disease when left ventricular dilation and systolic dysfunction are associated due to excessive volume overload. It is often combined with a dilated aortic annulus and ascending aorta. Surgical aortic valve replacement remains the gold standard treatment for severe aortic regurgitation. However, for patients at prohibitive surgical risk, transcatheter aortic valve replacement represents an attractive alternative. Various technical challenges are the absence of calcium at the level of the annulus which means no anchoring points nor fluoroscopic landmarks, the difficulty of valve sizing, and the increased stroke volume secondary to the aortic regurgitation making valve deployment more unstable than in the setting of aortic stenosis. The first-generation transcatheter valves were associated with a higher mortality rate and lower procedural success in relation to increased risk of paravalvular leak, valve migration requiring a second valve or annular rupture than the more recent off-label or on-label transcatheter valves. Early studies with the dedicated on-label devices showed safety and promising results and will undoubtedly serve in the future a growing number of patients with native aortic regurgitation at prohibitive risk for surgery.

Transcatheter aortic valve implantation (TAVI) is performed through a retrograde transfemoral approach in approximately 80–90 % of cases thanks to the improvements in delivery catheter profile, size and steerability compared with the first generation devices. The aim of this review article is to describe the challenges of transfemoral TAVI and the options to overcome them. The difficulties may be related to the access itself or the placement of the valve using the transfemoral route. Comprehensive patient screening using multislice computed tomography and crossover techniques to prevent bleeding should result in low complication rates even for fully percutaneous procedures. Horizontal ascending aorta and severely calcified aortic valves remain a challenge for retrograde valve crossing, device advancement and accurate positioning during deployment. The buddy balloon technique is a simple option in the case of difficult aortic valve crossing with a delivery catheter, whereas an antegrade approach using the transapical route is a reasonable alternative in such anatomy.