The Emerging Role of Lithotripsy in Structural Heart Interventions

Lithotripsy, first applied to treating nephrolithiasis, has an evolving role in cardiovascular disease, including intravascular treatment of calcified coronary and peripheral artery disease. Its role is expanding to the management of valvular and structural heart disease. This narrative review provides an overview of the emerging role of lithotripsy in various valvular and structural heart interventions.

We have conducted a comprehensive literature review of all publications on lithotripsy in structural heart interventions found in PubMed and Google Scholar. We have also included a series of case examples of lithotripsy in structural heart interventions from a tertiary referral center in the United States (Henry Ford Health, Michigan). Lithotripsy has been used to facilitate large-bore access in both transfemoral and alternative access procedures, to treat valvular stenosis of mitral and aortic valves, manage paravalvular leak closure, aid transcatheter electrosurgery, and manage endovascular, congenital, and structural electrophysiology procedures. While a nationwide registry is available for large-bore access facilitation, the current data on valvular stenosis is limited to single-center registries. Data on most other applications is restricted to case reports and case series and is subject to publication bias. Only two studies have been published on ex vivo and translational models.

Lithotripsy is increasingly used off-label in structural heart interventions, with early clinical successes being reported. Translational research and bench-testing models are necessary to determine the optimal energy transfer conditions for valvular and annular lithotripsy. Multi-center studies and randomized controlled trials are needed to assess the efficacy of these novel procedures.

Graphical abstract showing the number of cases reported each application of lithotripsy in structural heart interventions at its current role in structural heart interventions. Its role in large-bore access facilitation is established and gaining momentum. Its role in valvular lithotripsy is emerging, with dedicated devices in development. Its role in other procedures such as paravalvular leak closure, leaflet modification and congenital heart interventions is largely exploratory.

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