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Leone PP, Regazzoli D, Pagnesi M, Costa G, Teles R, Adamo M, Taramasso M, De Marco F, Mangieri A, Kargoli F, Ohno Y, Saia F, Ielasi A, Ribichini F, Maffeo D, Kim WK, Maisano F, Van Mieghem NM, Colombo A, Reimers B, Latib A. Prosthesis-patient mismatch after transcatheter implantation of contemporary balloon-expandable and self-expandable valves in small aortic annuli. Catheter Cardiovasc Interv 2023; 102:931-943. [PMID: 37668097 DOI: 10.1002/ccd.30818] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/29/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Evidence of clinical impact of PPM after TAVI is conflicting and might vary according to the type of valve implanted. AIMS To assess the clinical impact of prosthesis-patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI) with balloon-expandable (BEV) and self-expandable valves (SEV) in patients with small annuli. METHODS TAVI-SMALL 2 enrolled 628 patients in an international retrospective registry, which included patients with severe aortic stenosis and small annuli (annular perimeter <72 mm or area <400 mm2 ) treated with transfemoral TAVI at 16 high-volume centers between 2011 and 2020. Analyses were performed comparing patients with less than moderate (n = 452), moderate (n = 138), and severe PPM (n = 38). Primary endpoint was incidence of all-cause mortality. Predictors of all-cause mortality and PPM were investigated. RESULTS At a median follow-up of 380 days (interquartile range: 210-709 days), patients with severe PPM, but not moderate PPM, had an increased risk of all-cause mortality when compared with less than moderate PPM (log-rank p = 0.046). Severe PPM predicted all-cause mortality in patients with BEV (hazard ratio [HR]: 5.20, 95% confidence interval [CI]: 1.27-21.2) and intra-annular valves (IAVs, HR: 4.23, 95% CI: 1.28-14.02), and it did so with borderline significance in the overall population (HR: 2.89, 95% CI: 0.95-8.79). Supra-annular valve (SAV) implantation was the only predictor of severe PPM (odds ratio: 0.33, 95% CI: 0.13-0.83). CONCLUSIONS Patients with small aortic annuli and severe PPM after TAVI have an increased risk of all-cause mortality at early term follow-up, especially after IAV or BEV implantation. TAVI with SAV protected from severe PPM.
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Affiliation(s)
- Pier Pasquale Leone
- Division of Cardiology, Montefiore Medical Center, Bronx, New York, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Damiano Regazzoli
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Matteo Pagnesi
- Department of Medical and Surgical specialties, Radiological Sciences and Public Health, Institute of Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Giuliano Costa
- U.O.C. Cardiologia, Centro Alte Specialità e Trapianti, A.O.U. Policlinico "G. Rodolico-San Marco", Catania, Italy
| | - Rui Teles
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Nova Medical School, CEDOC, Lisbon, Portugal
| | - Marianna Adamo
- Department of Medical and Surgical specialties, Radiological Sciences and Public Health, Institute of Cardiology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Maurizio Taramasso
- HerzZentrum Hirslanden Zurich, University of Zurich, Zurich, Switzerland
| | - Federico De Marco
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Faraj Kargoli
- Division of Cardiology, Montefiore Medical Center, Bronx, New York, USA
| | - Yohei Ohno
- Department of Cardiology, Tokai University Hospital, Kanagawa, Japan
| | - Francesco Saia
- Cardiology Unit, St. Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alfonso Ielasi
- Clinical and Interventional Unit, Sant'Ambrogio Cardio-Thoracic Center, Milan, Italy
| | - Flavio Ribichini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Diego Maffeo
- Cardiovascular Department, Interventional Cardiology Unit, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Won-Keun Kim
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
| | - Francesco Maisano
- Cardio-Thoracic-Vascular Department, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Antonio Colombo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Bernhard Reimers
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Bronx, New York, USA
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Herrmann HC, Abdel-Wahab M, Attizzani GF, Batchelor W, Bleiziffer S, Verdoliva S, Chang Y, Gada H, Gillam L, Guerrero M, Mahoney PD, Petronio AS, Rogers T, Rovin J, Szerlip M, Whisenant B, Mehran R, Tchetche D. Rationale and design of the SMall Annuli Randomized To Evolut or SAPIEN Trial (SMART Trial). Am Heart J 2022; 243:92-102. [PMID: 34587510 DOI: 10.1016/j.ahj.2021.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The SMall Annuli Randomized To Evolut or SAPIEN (SMART) Trial was designed to compare the performance of the two most widely available commercial transcatheter aortic valve replacement (TAVR) devices in patients with symptomatic severe native aortic stenosis with a small aortic valve annulus undergoing transfemoral TAVR. Patients with small aortic valve annuli are typically female and are often underrepresented in clinical trials. METHODS The SMART Trial is an international, prospective, multi-center, randomized controlled, post-market trial. The trial will be conducted in approximately 700 subjects at approximately 90 sites globally. Inclusion criteria include severe aortic stenosis, aortic valve annulus area of ≤430 mm2 based on multi-detector computed tomography, and appropriate anatomy for both the Medtronic Evolut PRO/PRO+ self-expanding and Edwards SAPIEN 3/3 Ultra balloon-expandable devices. The primary clinical outcome composite endpoint is defined as mortality, disabling stroke or heart failure rehospitalization at 12 months. The co-primary valve function composite endpoint is defined as bioprosthetic valve dysfunction at 12 months which includes hemodynamic structural valve dysfunction, defined as a mean gradient ≥20 mmHg, non-structural valve dysfunction, defined as severe prothesis-patient mismatch or ≥moderate aortic regurgitation, thrombosis, endocarditis, and aortic valve re-intervention. Powered secondary endpoints will be assessed hierarchically. CONCLUSIONS The SMART trial will be the largest head-to-head comparative trial of transfemoral TAVR using the two most widely available contemporary TAVR devices in the setting of small aortic annuli and the largest trial to enroll primarily women. CLINICAL TRIAL REGISTRATION URL: www.clinicaltrials.gov, Unique identifier: NCT04722250.
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Ternacle J, Pibarot P, Herrmann HC, Kodali S, Leipsic J, Blanke P, Jaber W, Mack MJ, Clavel MA, Salaun E, Guzzetti E, Annabi MS, Bernier M, Beaudoin J, Khalique OK, Weissman NJ, Douglas P, Bax J, Dahou A, Xu K, Alu M, Rogers E, Leon M, Thourani VH, Abbas AE, Hahn RT. Prosthesis-Patient Mismatch After Aortic Valve Replacement in the PARTNER 2 Trial and Registry. JACC Cardiovasc Interv 2021; 14:1466-1477. [PMID: 34238557 DOI: 10.1016/j.jcin.2021.03.069] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study aimed to compare incidence and impact of measured prosthesis-patient mismatch (PPMM) versus predicted PPM (PPMP) after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). BACKGROUND TAVR studies have used measured effective orifice area indexed (EOAi) to body surface area (BSA) to define PPM, but most SAVR series have used predicted EOAi. This difference may contribute to discrepancies in incidence and outcomes of PPM between series. METHODS The study analyzed SAVR patients from the PARTNER (Placement of Aortic Transcatheter Valves) 2A trial and TAVR patients from the PARTNER 2 SAPIEN 3 Intermediate Risk registry. PPM was classified as moderate if EOAi ≤0.85 cm2/m2 (≤0.70 if obese: body mass index ≥30 kg/m2) and severe if EOAi ≤0.65 cm2/m2 (≤0.55 if obese). PPMM was determined by the core lab-measured EOAi on 30-day echocardiogram. PPMP was determined by 2 methods: 1) using normal EOA reference values previously reported for each valve model and size (PPMP1; n = 929 SAVR, 1,069 TAVR) indexed to BSA; and 2) using normal reference EOA predicted from aortic annulus size measured by computed tomography (PPMP2; n = 864 TAVR only) indexed to BSA. Primary endpoint was the composite of 5-year all-cause death and rehospitalization. RESULTS The incidence of moderate and severe PPMP was much lower than PPMM in both SAVR (PPMP1: 28.4% and 1.2% vs. PPMM: 31.0% and 23.6%) and TAVR (PPMP1: 21.0% and 0.1% and PPMP2: 17.0% and 0% vs. PPMM: 27.9% and 5.7%). The incidence of severe PPMM and severe PPMP1 was lower in TAVR versus SAVR (P < 0.001). The presence of PPM by any method was associated with higher transprosthetic gradient. Severe PPMP1 was independently associated with events in SAVR after adjustment for sex and Society of Thoracic Surgeons score (hazard ratio: 3.18;95% CI: 1.69-5.96; P < 0.001), whereas no association was observed between PPM by any method and outcomes in TAVR. CONCLUSIONS EOAi measured by echocardiography results in a higher incidence of PPM following SAVR or TAVR than PPM based on predicted EOAi. Severe PPMP is rare (<1.5%), but is associated with increased all-cause death and rehospitalization after SAVR, whereas it is absent following TAVR.
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Affiliation(s)
- Julien Ternacle
- Québec Heart and Lung Institute, Université Laval, Quebec City, Quebec, Canada
| | - Philippe Pibarot
- Québec Heart and Lung Institute, Université Laval, Quebec City, Quebec, Canada.
| | - Howard C Herrmann
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susheel Kodali
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Jonathon Leipsic
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philipp Blanke
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Marie-Annick Clavel
- Québec Heart and Lung Institute, Université Laval, Quebec City, Quebec, Canada
| | - Erwan Salaun
- Québec Heart and Lung Institute, Université Laval, Quebec City, Quebec, Canada
| | - Ezequiel Guzzetti
- Québec Heart and Lung Institute, Université Laval, Quebec City, Quebec, Canada
| | | | - Mathieu Bernier
- Québec Heart and Lung Institute, Université Laval, Quebec City, Quebec, Canada
| | - Jonathan Beaudoin
- Québec Heart and Lung Institute, Université Laval, Quebec City, Quebec, Canada
| | - Omar K Khalique
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Neil J Weissman
- MedStar Heath Research Institute, Georgetown University, Washington, DC, USA
| | - Pamela Douglas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeroen Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Ke Xu
- Edwards Lifesciences, Irvine, California, USA
| | - Maria Alu
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Erin Rogers
- Edwards Lifesciences, Irvine, California, USA
| | - Martin Leon
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Amr E Abbas
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan, USA; Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA
| | - Rebecca T Hahn
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
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Herrmann HC. Small Annulus, Hemodynamic Status, and TAVR. JACC Cardiovasc Interv 2021; 14:1229-1230. [PMID: 34112459 DOI: 10.1016/j.jcin.2021.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Howard C Herrmann
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Leone PP, Regazzoli D, Pagnesi M, Sanz-Sanchez J, Chiarito M, Cannata F, Van Mieghem NM, Barbanti M, Tamburino C, Teles R, Adamo M, Miura M, Maisano F, Kim WK, Bedogni F, Stefanini G, Mangieri A, Giannini F, Colombo A, Reimers B, Latib A. Predictors and Clinical Impact of Prosthesis-Patient Mismatch After Self-Expandable TAVR in Small Annuli. JACC Cardiovasc Interv 2021; 14:1218-1228. [PMID: 34112458 DOI: 10.1016/j.jcin.2021.03.060] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/01/2021] [Accepted: 03/23/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this study was to define predictors of prosthesis-patient mismatch (PPM) and its impact on mortality after transcatheter aortic valve replacement (TAVR) with self-expandable valves (SEVs) in patients with small annuli. BACKGROUND TAVR seems to reduce the risk for PPM compared with surgical aortic valve replacement, especially in patients with small aortic annuli. Nevertheless, predictors and impact of PPM in this population have not been clarified yet. METHODS Predictors of PPM and all-cause mortality were investigated using multivariable logistic regression analysis from the cohort of the TAVI-SMALL (International Multicenter Registry to Evaluate the Performance of Self-Expandable Valves in Small Aortic Annuli) registry, which included patients with severe aortic stenosis and small annuli (annular perimeter <72 mm or area <400 mm2 on computed tomography) treated with transcatheter SEVs: 445 patients with (n = 129) and without (n = 316) PPM were enrolled. RESULTS Intra-annular valves conferred increased risk for PPM (odds ratio [OR]: 2.36; 95% confidence interval [CI]: 1.16 to 4.81), while post-dilation (OR: 0.46; 95% CI: 0.25-0.84) and valve oversizing (OR: 0.53; 95% CI: 0.28-1.00) seemed to protect against PPM occurrence. At a median follow-up of 354 days, patients with severe PPM, but not those with moderate PPM, had a higher all-cause mortality rate compared with those without PPM (log-rank p = 0.008). Multivariable Cox regression confirmed severe PPM as an independent predictor of all-cause mortality (hazard ratio: 4.27; 95% CI: 1.34 to 13.6). CONCLUSIONS Among patients with aortic stenosis and small aortic annuli undergoing transcatheter SEV implantation, use of intra-annular valves yielded higher risk for PPM; conversely, post-dilation and valve oversizing protected against PPM occurrence. Severe PPM was independently associated with all-cause mortality.
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Affiliation(s)
- Pier Pasquale Leone
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | | | - Matteo Pagnesi
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | | | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco Cannata
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marco Barbanti
- U.O.C. Cardiologia, Centro Alte Specialità e Trapianti, P.O.G. Rodolico, A.O.U. Policlinico-V. Emanuele, Università di Catania, Catania, Italy
| | - Corrado Tamburino
- U.O.C. Cardiologia, Centro Alte Specialità e Trapianti, P.O.G. Rodolico, A.O.U. Policlinico-V. Emanuele, Università di Catania, Catania, Italy
| | - Rui Teles
- Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Lisbon, Portugal
| | - Marianna Adamo
- Civil Hospital and University of Brescia, Brescia, Italy
| | - Mizuki Miura
- Cardiac Surgery, University of Zürich, Zürich, Switzerland
| | | | - Won-Keun Kim
- Department of Cardiology and Cardiac Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Francesco Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | | | | | - Antonio Colombo
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Italy; GVM Care and Research, Maria Cecilia Hospital, Ravenna, Italy
| | - Bernhard Reimers
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Bronx, New York, USA
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