Long-term Follow-up After Transcatheter Aortic Valve Replacement

Transcatheter Aortic Valve Replacement (TAVR) Versus Surgical Aortic Valve Replacement (SAVR): A Review on the Length of Stay, Cost, Comorbidities, and Procedural Complications

This review provides an in-depth analysis of the effect of length of stay (LOS), comorbidities, and procedural complications on the cost-effectiveness of transcatheter aortic valve replacement (TAVR) in comparison to surgical aortic valve replacement (SAVR). We found that the average LOS was shorter for patients undergoing TAVR, contributing to lower average costs associated with the procedure, although the LOS varied between patients due to the severity of illness and comorbidities present. TAVR has also been found to improve the quality of life for patients receiving aortic valve replacement compared to SAVR. Although TAVR has a lower rate of most post-operative complications caused by SAVR, such as bleeding and cardiac complications, TAVR shows an increased rate of permanent pacemaker (PPM) implantation due to mechanical trauma on the heart's conduction system. In addition, our findings suggest that the cost-effectiveness of each procedure varies based on the types of valve, the patient history of other medical conditions, and the procedural methods. Our findings show that TAVR is preferred over SAVR in terms of cost-effectiveness across a variety of patients with other coexisting medical conditions, including cancer, advanced kidney disease, cirrhosis, diabetes mellitus, and bundle branch block. TAVR also appears to be superior to SAVR with fewer post-operative complications. However, TAVR appears to have a higher rate of PPM implantation rates as compared to SAVR. The comorbidities of the valve recipient must be considered when deciding whether to use TAVR or SAVR as cost-effectiveness varies with the patient background.

A rare delayed complication after TAVR: Acute severe aortic insufficiency

Transcatheter aortic valve replacement (TAVR) has become the standard of care for managing severe aortic stenosis (AS) in high surgical risk patients. Despite favorable outcomes, TAVR has been associated with complications, such as aortic regurgitation (AR). Post-TAVR aortic insufficiency, which can present at any time after the procedure, manifests as paravalvular leak, central leak, or a combination of the two. Herein, we describe a unique and atypical case of a patient who presented with heart failure and was found to have severe AR in the context of having had TAVR 5 years prior using an Evolut R prosthetic valve.

Evaluating the effect of multivalvular disease on mortality after transcatheter aortic valve replacement for aortic stenosis: a meta-analysis and systematic review

Aims: To determine the prognosis of multivalvular disease in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Methods: Patients undergoing TAVR for aortic stenosis with covariate-adjusted risk of mortality associated with concomitant valve disease (mitral regurgitation [MR], mitral stenosis [MS] or tricuspid regurgitation [TR]) were included. Results: Moderate-to-severe MR was associated with increased mortality at 30 days (hazard ratio [HR]: 1.60; 95% CI: 1.11-2.30; p = 0.01) and 1 year (HR: 1.87; 95% CI: 1.22-2.87; p = 0.004). The presence of all-grade MS did not impact 30-day or 1-year mortality (HR, 30 days: 1.60; 95% CI: 0.71-3.63; p = 0.26; and HR, 1 year: 1.90; 95% CI: 0.98-3.69; p = 0.06); however, an increased risk of 1-year mortality (HR: 1.67; 95% CI: 1.03-2.70; p = 0.04) was observed with severe MS compared with no MS. Moderate-to-severe TR had a higher risk of all-cause mortality at 1 year (HR: 1.49; 95% CI: 1.24-1.78; p < 0.001) compared with no or mild TR. Conclusion: Moderate-to-severe MR or TR, and severe MS, significantly increase mid-term mortality after TAVR.

Surgery after Failed Transcatheter Aortic Valve Implantation: Indications and Outcomes of a Concerning Condition

OBJECTIVES

The number of transcatheter aortic valve implantations (TAVI) has increased enormously in recent decades. Transcatheter valve prosthesis failure and the requirement of conventional surgical replacement are expected to attract more focus in the near future. Indeed, given the scarcity of research in this field, the next decade will likely represent the beginning of a period of meaningful exploration of the degenerative changes that occur with transcatheter valves. The current study represents-through a series of consecutive cases-one of the first analyses of the underlying causes of TAVI failure, i.e., degenerative, functional and infective, followed by surgical aortic valve replacement (SAVR) and postoperative outcome.

METHODS

Between October 2008 and March 2021, 2098 TAVI procedures, including 1423 with transfemoral, 309 with transapical, and 366 with transaortic access, were performed in our institution. Among these, 0.5% (number(n) = 11) required acute SAVR (n = 6) within 7 days (n = 3) or later (n = 2), and were included in the study.

RESULTS

Valve stent dislocation was the most common cause of replacement (83%). Causes of replacement within 7 days after TAVI were multifactorial. In the later course, endocarditis was the sole indication for SAVR after TAVI. TAVI with transapical or transaortal approach had a higher EuroSCORE II (10.9 (7.2-35.3) vs. 3.5 (1.8-7.8)). Their 30-day mortality after surgical conversion was higher (67% vs. 20%), when compared to those who underwent a transfemoral procedure. The longest documented survival beyond 30 days was 58 months.

CONCLUSIONS

The causes of SAVR after TAVI failure are multifactorial, and include biological, physical and infectious factors. An acceptable midterm prognosis may be expected in patients with physical causes when dislocation of the catheter prosthesis is observed; in such cases, emergency conversion is required. Conversion due to infection, as in cases of endocarditis, had the worst outcome. Prognosis after conversion due to degeneration is still problematic, due to a lack of autopsies and the recent history of prosthetic implantations.