1
|
Baumbach A, Patel KP, Rudolph TK, Delgado V, Treede H, Tamm AR. Aortic regurgitation: from mechanisms to management. EUROINTERVENTION 2024; 20:e1062-e1075. [PMID: 39219357 PMCID: PMC11352546 DOI: 10.4244/eij-d-23-00840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Aortic regurgitation (AR) is a common clinical disease associated with significant morbidity and mortality. Investigations based largely on non-invasive imaging are pivotal in discerning the severity of disease and its impact on the heart. Advances in technology have contributed to improved risk stratification and to our understanding of the pathophysiology of AR. Surgical aortic valve replacement is the predominant treatment. However, its use is limited to patients with an acceptable surgical risk profile. Transcatheter aortic valve implantation is an alternative treatment. However, this therapy remains in its infancy, and further data and experience are required. This review article on AR describes its prevalence, mechanisms, diagnosis and treatment.
Collapse
Affiliation(s)
- Andreas Baumbach
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Tanja K Rudolph
- Department of General and Interventional Cardiology and Angiology, Heart and Diabetes Center NRW, Ruhr University, Bad Oeynhausen, Germany
| | - Victoria Delgado
- University Hospital, Germans Trias i Pujol Hospital, Badalona, Spain
- Centre for Comparative Medicine and Bioimage (CMCiB) of the Germans Trias I Pujol, Badalona, Spain
| | - Hendrik Treede
- Department of Cardiac and Vascular Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alexander R Tamm
- Department of Cardiology, Cardiology I, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| |
Collapse
|
2
|
Le Ruz R, Leroux L, Lhermusier T, Cuisset T, Van Belle E, Dibie A, Palermo V, Champagnac D, Obadia JF, Teiger E, Ohlman P, Tchétché D, Le Breton H, Saint-Etienne C, Piriou PG, Plessis J, Beurtheret S, Du Chayla F, Leclère M, Lefèvre T, Collet JP, Eltchaninoff H, Gilard M, Iung B, Manigold T, Letocart V, Of Stop-As And France-Tavi Investigators OB. Outcomes of transcatheter aortic valve implantation for native aortic valve regurgitation. EUROINTERVENTION 2024; 20:e1076-e1085. [PMID: 39219361 PMCID: PMC11363660 DOI: 10.4244/eij-d-24-00339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/25/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Large datasets of transcatheter aortic valve implantation (TAVI) for pure aortic valve regurgitation (PAVR) are scarce. AIMS We aimed to report procedural safety and long-term clinical events (CE) in a contemporary cohort of PAVR patients treated with new-generation devices (NGD). METHODS Patients with grade III/IV PAVR enrolled in the FRANCE-TAVI Registry were selected. The primary safety endpoint was technical success (TS) according to Valve Academic Research Consortium 3 criteria. The co-primary endpoint was defined as a composite of mortality, heart failure hospitalisation and valve reintervention at last follow-up. RESULTS From 2015 to 2021, 227 individuals (64.3% males, median age 81.0 [interquartile range {IQR} 73.5-85.0] years, with EuroSCORE II 6.0% [IQR 4.0-10.9]) from 41 centres underwent TAVI with NGD, using either self-expanding (55.1%) or balloon-expandable valves (44.9%; p=0.50). TS was 85.5%, with a non-significant trend towards increased TS in high-volume activity centres. A second valve implantation (SVI) was needed in 8.8% of patients, independent of valve type (p=0.82). Device size was ≥29 mm in 73.0% of patients, post-procedure grade ≥III residual aortic regurgitation was rare (1.2%), and the permanent pacemaker implantation (PPI) rate was 36.0%. At 30 days, the incidences of mortality and reintervention were 8.4% and 3.5%, respectively. The co-primary endpoint reached 41.6% (IQR 34.4-49.6) at 1 year, increased up to 61.8% (IQR 52.4-71.2) at 4 years, and was independently predicted by TS, with a hazard ratio of 0.45 (95% confidence interval: 0.27-0.76); p=0.003. CONCLUSIONS TAVI with NGD in PAVR patients is efficient and reasonably safe. Preventing the need for an SVI embodies the major technical challenge. Larger implanted valves may have limited this complication, outweighing the increased risk of PPI. Despite successful TAVI, PAVR patients experience frequent CE at long-term follow-up.
Collapse
Affiliation(s)
- Robin Le Ruz
- Interventional Cardiology Department, Nantes Université, CHU Nantes, L'institut du thorax, Nantes, France
- Nantes Université, CHU Nantes, CNRS, INSERM, L'institut du thorax, Nantes, France
| | - Lionel Leroux
- Department of Cardiology and Cardiovascular Surgery, Hôpital Cardiologique de Haut-Lévêque, Pessac, France
| | | | - Thomas Cuisset
- Centre for Cardiovascular and Nutrition Research, Aix Marseille Université, Marseille, France
| | - Eric Van Belle
- University of Lille, INSERM, Centre Hospitalier Universitaire Lille, Institut Pasteur de Lille, Lille, France
| | - Alain Dibie
- Institut Mutualiste Montsouris, Paris, France
| | - Vincenzo Palermo
- Hôpital Marie-Lannelongue (groupe hospitalier Paris Saint-Joseph), Le Plessis-Robinson, France
| | | | - Jean-François Obadia
- Clinical Investigation Center & Heart Failure Department, Hôpital Cardiovasculaire Louis Pradel, INSERM 1407, Hospices Civils de Lyon and Claude Bernard University, Lyon, France
| | - Emmanuel Teiger
- Department of Cardiology, APHP, Henri-Mondor University Hospital, Créteil, France
| | - Patrick Ohlman
- Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France
| | | | - Hervé Le Breton
- Department of Cardiology, University of Rennes, CHU Rennes, INSERM, LTSI - UMR 1099, Rennes, France
| | | | - Pierre-Guillaume Piriou
- Interventional Cardiology Department, Nantes Université, CHU Nantes, L'institut du thorax, Nantes, France
| | - Julien Plessis
- Interventional Cardiology Department, Nantes Université, CHU Nantes, L'institut du thorax, Nantes, France
| | | | | | | | - Thierry Lefèvre
- Institut Cardiovasculaire Paris Sud, Hôpital privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Jean-Philippe Collet
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Hélène Eltchaninoff
- Department of Cardiology, University Rouen Normandie, INSERM U1096, CHU Rouen, Rouen, France
| | - Martine Gilard
- Department of Cardiology, Brest University Hospital, Brest, France
| | - Bernard Iung
- Department of Cardiology, Université Paris-Cité, Paris, France and Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
| | - Thibaut Manigold
- Interventional Cardiology Department, Nantes Université, CHU Nantes, L'institut du thorax, Nantes, France
| | - Vincent Letocart
- Interventional Cardiology Department, Nantes Université, CHU Nantes, L'institut du thorax, Nantes, France
| | | |
Collapse
|
3
|
Delgado V, Peláez ED. Severe aortic regurgitation: the limits of TAVI. EUROINTERVENTION 2024; 20:e1051-e1052. [PMID: 39229834 PMCID: PMC11352525 DOI: 10.4244/eij-e-24-00045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Affiliation(s)
- Victoria Delgado
- Heart Institute, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Elena Díaz Peláez
- Heart Institute, University Hospital Germans Trias i Pujol, Badalona, Spain
| |
Collapse
|
4
|
Barbanti M, Laterra G, Maisano F. Transcatheter treatment of pure aortic regurgitation. Nat Rev Cardiol 2024; 21:597-598. [PMID: 38937627 DOI: 10.1038/s41569-024-01059-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
| | | | - Francesco Maisano
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
5
|
Kong XQ, Zhang J, Gao XF, Wang ZM, Ye P, Zhang JJ, Chen SL. Single-center experience with self-expanding transcatheter aortic valve system for symptomatic high-risk patients with severe aortic regurgitation: One-year outcomes. Catheter Cardiovasc Interv 2024. [PMID: 39189047 DOI: 10.1002/ccd.31193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 05/25/2024] [Accepted: 08/11/2024] [Indexed: 08/28/2024]
Abstract
AIMS To evaluate the safety and efficacy of transcatheter aortic valve implantation (TAVI) for the treatment of aortic regurgitation (AR). METHODS From September 2019 to February 2022, 62 patients who underwent transfemoral TAVI procedure for pure, symptomatic severe AR with the VitaFlow system were enrolled in the current study. The outcomes were assessed according to the Valve Academic Research Consortium 3 criteria. Procedural results and clinical outcomes for 1 year were analyzed. RESULTS The mean age was 71.56 ± 7.34 years and 58.1% were male. The mean Society of Thoracic Surgeons score was 5.44 ± 3.22%. The device success rate was 79.0%. Only one patient was converted to open surgery. The in-hospital mortality rate was 1.6%. The 1-year all-cause mortality rate was 6.5%. The new permanent pacemaker implantation rate was 29.0% in-hospital and 30.7% at 1-year follow-up. The second valve implantation rate was 14.5%. No patient developed more than moderate paravalvular leakage during follow-up. The mean ejection fraction improved from 54.05 ± 10.83% at baseline to 59.32 ± 8.70% (p < 0.001 compared with baseline) at 12 months. Left ventricular end-diastolic diameter decreased from 61.62 ± 5.58 mm at baseline to 55.20 ± 4.51 mm (p < 0.001 compared with the baseline) at 12 months. CONCLUSIONS Transfemoral TAVI procedure shows efficacy in treating patients with severe pure native AR. The safety is improved with the development of the VitaFlow system.
Collapse
Affiliation(s)
- Xiang-Quan Kong
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Juan Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao-Fei Gao
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhi-Mei Wang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Peng Ye
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jun-Jie Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| |
Collapse
|
6
|
Poletti E, Amat-Santos I, Criscione E, Popolo Rubbio A, García-Gómez M, Orzalkiewicz M, Pan M, Sisinni A, Squillace M, Del Blanco BG, Bruno F, Panoulas V, Pracon R, De Backer O, Taramasso M, Costa G, Barbanti M, Van Mieghem NM, Regazzoli D, Mangieri A, Scotti A, Latib A, Saia F, Bedogni F, Testa L. Performance of balloon-expandable transcatheter bioprostheses in inoperable patients with pure aortic regurgitation of a native valve: The BE-PANTHEON international project. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00630-4. [PMID: 39198100 DOI: 10.1016/j.carrev.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/19/2024] [Accepted: 08/14/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND The off-label utilization of transcatheter heart valve (THV) devices for the treatment of inoperable or high-surgical risk patients with pure native aortic valve regurgitation (NAVR) has demonstrated suboptimal outcomes, both with self- and balloon-expandable (BE) devices. The aim of this study is to compare the use of different BE scaffolds in treating pure NAVR. METHODS Consecutive patients with pure severe NAVR who were deemed to be at high-risk and were treated with last-generation BE-THVs among seventeen Centers in Europe and US. Technical and device success rates were the primary objectives. RESULTS Between February 2018 and July 2023, among 144 patients, 41 (28 %) received a MyVal device and 103 (72 %) were treated with a Sapien THV. Patients treated with a MyVal THV had an extra-large annulus more frequently compared to the Sapien group (49%vs.20 %, p < 0.001). Technical and device success rates were 90 % and 81 %, respectively, p > 0.1. The rate of THV migration/embolization (MyVal 4.9%vs. Sapien 11 %, p = 0.4) and second valve needed (4.9%vs.7.8 %, p = 0.7) were numerically lower in the MyVal group, whereas the rate of at least moderate paravalvular leak (15%vs.7.8 %, p = 0.2) and permanent pacemaker implantation (25%vs.18 %, p = 0.16) were numerically higher in the Myval group. CONCLUSIONS Off-label use of BE devices for pure NAVR represents a potential alternative in high-risk patients in the absence of dedicated devices. However, BE in NAVR is associated with suboptimal outcomes. The availability of larger THV sizes may introduce transcatheter aortic valve replacement as an effective treatment for patients traditionally deemed unsuitable. NON-STANDARD ABBREVIATIONS AND ACRONYMS AR = aortic regurgitation, BE = balloon-expandable, NAVR = native aortic valve regurgitation, PM = pacemaker, TAVR = transcatheter aortic valve replacement, THV = transcatheter heart valve, TVEM = transcatheter valve embolization and migration, VARC-3 = Valve Academic Research Consortium 3.
Collapse
Affiliation(s)
- Enrico Poletti
- Clinical and Interventional Cardiology Department, I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Ignacio Amat-Santos
- Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Enrico Criscione
- Clinical and Interventional Cardiology Department, I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Antonio Popolo Rubbio
- Clinical and Interventional Cardiology Department, I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Mario García-Gómez
- Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Mateusz Orzalkiewicz
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Bologna, Italy
| | - Manuel Pan
- Department of Cardiology, Hospital Universitario Reina Sofía, University of Córdoba, IMIBIC - CIBERCV, Spain
| | - Antonio Sisinni
- Clinical and Interventional Cardiology Department, I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Mattia Squillace
- Clinical and Interventional Cardiology Department, I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Francesco Bruno
- Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, United Kingdom of Great Britain and Northern Ireland
| | - Vasileios Panoulas
- Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, United Kingdom of Great Britain and Northern Ireland; Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, United Kingdom of Great Britain and Northern Ireland
| | - Radoslaw Pracon
- Harefield Hospital, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, United Kingdom of Great Britain and Northern Ireland
| | - Ole De Backer
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Giuliano Costa
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico G. Rodolico - San Marco, University of Catania, Catania, Italy
| | | | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Damiano Regazzoli
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Antonio Mangieri
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Andrea Scotti
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Azeem Latib
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Francesco Saia
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Bologna, Italy
| | - Francesco Bedogni
- Clinical and Interventional Cardiology Department, I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Luca Testa
- Clinical and Interventional Cardiology Department, I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy.
| |
Collapse
|
7
|
Patterson T, Arri SS. Transcatheter Treatment of Pure Aortic Regurgitation: From Good to Great. JACC Cardiovasc Interv 2024; 17:1607-1608. [PMID: 38986660 DOI: 10.1016/j.jcin.2024.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/20/2024] [Indexed: 07/12/2024]
Affiliation(s)
- Tiffany Patterson
- Cardiovascular Department, Guy's and St. Thomas' NHS Foundation Trust, Heart Lung Critical Care Group, London, United Kingdom; Cardiovascular Department, King's College London, London, United Kingdom.
| | - Satpal Singh Arri
- Cardiovascular Department, Guy's and St. Thomas' NHS Foundation Trust, Heart Lung Critical Care Group, London, United Kingdom
| |
Collapse
|
8
|
Poletti E, Adam M, Wienemann H, Sisinni A, Patel KP, Amat-Santos IJ, Orzalkiewicz M, Saia F, Regazzoli D, Fiorina C, Panoulas V, Brinkmann C, Giordano A, Taramasso M, Maisano F, Barbanti M, De Backer O, Van Mieghem NM, Latib A, Squillace M, Baldus S, Geyer M, Baumbach A, Bedogni F, Rudolph TK, Testa L. Performance of Purpose-Built vs Off-Label Transcatheter Devices for Aortic Regurgitation: The PURPOSE Study. JACC Cardiovasc Interv 2024; 17:1597-1606. [PMID: 38986659 DOI: 10.1016/j.jcin.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Severe pure aortic regurgitation (AR) carries a high mortality and morbidity risk, and it is often undertreated because of the inherent surgical risk. Transcatheter heart valves (THVs) have been used off-label in this setting with overall suboptimal results. The dedicated "purpose-built" Jena Valve Trilogy (JVT, JenaValve Technology) showed an encouraging performance, although it has never been compared to other THVs. OBJECTIVES The aim of our study was to assess the performance of the latest iteration of THVs used off-label in comparison to the purpose-built JVT in inoperable patients with severe AR. METHODS We performed a multicenter, retrospective registry with 18 participating centers worldwide collecting data on inoperable patients with severe AR of the native valve. A bicuspid aortic valve was the main exclusion criterion. The primary endpoints were technical and device success, 1-year all-cause mortality, and the composite of 1-year mortality and the heart failure rehospitalization rate. RESULTS Overall, 256 patients were enrolled. THVs used off-label were used in 168 cases (66%), whereas JVT was used in 88 (34%). JVT had higher technical (81% vs 98%; P < 0.001) and device success rates (73% vs 95%; P < 0.001), primarily driven by significantly lower incidences of THV embolization (15% vs 1.1%; P < 0.001), the need for a second valve (11% vs 1.1%; P = 0.004), and moderate residual AR (10% vs 1.1%; P = 0.007). The permanent pacemaker implantation rate was comparable and elevated for both groups (22% vs 24%; P = 0.70). Finally, no significant difference was observed at the 1-year follow-up in terms of mortality (HR: 0.99; P = 0.980) and the composite endpoint (HR: 1.5; P = 0.355). CONCLUSIONS The JVT platform has a better acute performance than other THVs when used off-label for inoperable patients with severe AR. A longer follow-up is conceivably needed to detect a possible impact on prognosis.
Collapse
Affiliation(s)
- Enrico Poletti
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Matti Adam
- Department of Internal Medicine III-Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Hendrik Wienemann
- Department of Internal Medicine III-Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Antonio Sisinni
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Kush P Patel
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ignacio J Amat-Santos
- Instituto de Ciencias Del Corazón, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Mateusz Orzalkiewicz
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Bologna, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Bologna, Italy
| | - Damiano Regazzoli
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | | | - Vasileios Panoulas
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom
| | | | - Arturo Giordano
- Cardiovascular Interventional Operative Unit, Presidio Ospedaliero Pineta Grande, Castel Volturno, Caserta, Italy
| | - Maurizio Taramasso
- HerzZentrum Hirslanden Zurich Clinic of Cardiac Surgery, Zurich, Switzerland
| | | | | | - Ole De Backer
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Azeem Latib
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Stephan Baldus
- Department of Internal Medicine III-Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Martin Geyer
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Andreas Baumbach
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | | | - Tanja K Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Luca Testa
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
| |
Collapse
|
9
|
Al Ahmad J, Danson E. Transcatheter Aortic Valve Implantation for Severe Chronic Aortic Regurgitation. J Clin Med 2024; 13:2997. [PMID: 38792538 PMCID: PMC11122034 DOI: 10.3390/jcm13102997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/24/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has revolutionised the management of aortic valve disease, offering a less invasive alternative to traditional surgical valve replacement for severe aortic stenosis (AS). TAVI for pure aortic regurgitation (AR) is less well established, and, in fact, it was previously labelled as a relative contraindication. However, TAVI has been utilised for selected cases of pure or predominant AR. The primary limitations regarding the use of TAVI in AR are related to the absence of anatomical factors seen in patients with AS that have contributed to the safe and stable functioning of current-generation prostheses. These include aortic root dilatation, mobile valve leaflets and labile blood pressure within the aortic root, which may further increase the risk of valve migration and periprosthetic leak after deployment. Furthermore, patients with AR have more heterogeneous aortic root anatomies when compared to the population of patients with calcific or degenerative AS. This review article describes the current evidence for the off-label use of TAVI in pure AR and the various clinical syndromes associated with AR where there may be specific challenges in the application of TAVI.
Collapse
Affiliation(s)
- Judy Al Ahmad
- Department of Cardiology, Wollongong Hospital, Wollongong, NSW 2500, Australia
| | - Edward Danson
- Department of Cardiology, Wollongong Hospital, Wollongong, NSW 2500, Australia
| |
Collapse
|
10
|
Vahl TP, Thourani VH, Makkar RR, Hamid N, Khalique OK, Daniels D, McCabe JM, Satler L, Russo M, Cheng W, George I, Aldea G, Sheridan B, Kereiakes D, Golwala H, Zahr F, Chetcuti S, Yadav P, Kodali SK, Treede H, Baldus S, Amoroso N, Ranard LS, Pinto DS, Leon MB. Transcatheter aortic valve implantation in patients with high-risk symptomatic native aortic regurgitation (ALIGN-AR): a prospective, multicentre, single-arm study. Lancet 2024; 403:1451-1459. [PMID: 38552656 DOI: 10.1016/s0140-6736(23)02806-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/11/2023] [Accepted: 12/12/2023] [Indexed: 04/15/2024]
Abstract
BACKGROUND Surgery remains the only recommended intervention for patients with native aortic regurgitation. A transcatheter therapy to treat patients at high risk for mortality and complications with surgical aortic valve replacement represents an unmet need. Commercial transcatheter heart valves in pure aortic regurgitation are hampered by unacceptable rates of embolisation and paravalvular regurgitation. The Trilogy transcatheter heart valve (JenaValve Technology, Irvine, CA, USA) provides a treatment option for these patients. We report outcomes with transfemoral transcatheter aortic valve implantation (TAVI) in patients with pure aortic regurgitation using this dedicated transcatheter heart valve. METHODS The ALIGN-AR trial is a prospective, multicentre, single-arm study. We recruited symptomatic patients (aged ≥18 years) with moderate-to-severe or severe aortic regurgitation at high risk for mortality and complications after surgical aortic valve replacement at 20 US sites for treatment with the Trilogy transcatheter heart valve. The 30-day composite primary safety endpoint was compared for non-inferiority with a prespecified performance goal of 40·5%. The primary efficacy endpoint was 1-year all-cause mortality compared for non-inferiority with a performance goal of 25%. This trial is registered with ClinicalTrials.gov, NCT04415047, and is ongoing. FINDINGS Between June 8, 2018, and Aug 29, 2022, we screened 346 patients. We excluded 166 (48%) patients and enrolled 180 (52%) patients with symptomatic aortic regurgitation deemed high risk by the heart team and independent screening committee assessments. The mean age of the study population was 75·5 years (SD 10·8), and 85 (47%) were female, 95 (53%) were male, and 131 (73%) were White. Technical success was achieved in 171 (95%) patients. At 30 days, four (2%) deaths, two (1%) disabling strokes, and two (1%) non-disabling strokes occurred. Using standard Valve Academic Research Consortium-2 definitions, the primary safety endpoint was achieved, with events occurring in 48 (27% [97·5% CI 19·2-34·0]) patients (pnon-inferiority<0·0001), with new pacemaker implantation in 36 (24%) patients. The primary efficacy endpoint was achieved, with mortality in 14 (7·8% [3·3-12·3]) patients at 1 year (pnon-inferiority<0·0001). INTERPRETATION This study shows the safety and effectiveness of treating native aortic regurgitation using a dedicated transcatheter heart valve to treat patients with symptomatic moderate-to-severe or severe aortic regurgitation who are at high risk for mortality or complications after surgical aortic valve replacement. The observed short-term clinical and haemodynamic outcomes are promising as are signs of left ventricular remodelling, but long-term follow-up is necessary. FUNDING JenaValve Technology.
Collapse
Affiliation(s)
- Torsten P Vahl
- Columbia University Irving Medical Center, New York, NY, USA.
| | | | - Raj R Makkar
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Nadira Hamid
- Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | - David Daniels
- California Pacific Medical Center, San Francisco, CA, USA
| | | | - Lowell Satler
- Medstar Washington Hospital Center, Washington, DC, USA
| | - Mark Russo
- Rutgers University, New Brunswick, NJ, USA
| | - Wen Cheng
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Isaac George
- Columbia University Irving Medical Center, New York, NY, USA
| | | | - Brett Sheridan
- California Pacific Medical Center, San Francisco, CA, USA
| | | | | | - Firas Zahr
- Oregon Health Sciences, Portland, OR, USA
| | | | | | | | - Hendrik Treede
- University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stephan Baldus
- Clinic III for Internal Medicine, University Hospital Cologne, Cologne, Germany
| | | | - Lauren S Ranard
- Columbia University Irving Medical Center, New York, NY, USA
| | - Duane S Pinto
- Beth Israel Deaconess Medical Center, Interventional Cardiology Section, Division of Cardiology, Boston, MA, USA
| | - Martin B Leon
- Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
11
|
Argaw S, Azizgolshani N, Blitzer D, Takayama H, George I, Pirelli L. Treatment options for isolated aortic valve insufficiency: a review. Front Cardiovasc Med 2024; 11:1381102. [PMID: 38665234 PMCID: PMC11043486 DOI: 10.3389/fcvm.2024.1381102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Aortic insufficiency (AI) is a valvular disease with increasing prevalence in older patients. The modern era provides numerous options for the management of AI which is explored here. Traditional interventions included aortic valve replacement with either mechanical or bioprosthetic aortic valves. While the former is known for its durability, it has grown out of favor due to the potential complications of anticoagulation. The preference for bioprosthetic valves is thus on the rise, especially with the advancements of transcatheter technology and the use of valve-in-valve therapy. Surgical options are also no longer limited to replacement but include complex techniques such as those required for aortic valve repair, Ozaki neocuspidization, Ross procedure and valve-sparring aortic root repair. Transcatheter options for the management of AI are not commercially available currently; however, preliminary data from ad-hoc trials, showed promising results and potential use of transcatheter technology in a variety of patients with pure AI.
Collapse
Affiliation(s)
| | | | | | | | | | - Luigi Pirelli
- Division of Cardiovascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, United States
| |
Collapse
|
12
|
Dreyfus J, Messika-Zeitoun D. Advancing transcatheter valve replacement for severe aortic regurgitation: Innovations in devices and multi-modality imaging. Echocardiography 2024; 41:e15807. [PMID: 38549431 DOI: 10.1111/echo.15807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/02/2024] Open
Affiliation(s)
- Julien Dreyfus
- Cardiology Department, Centre Cardiologique du Nord, Saint-Denis, France
| | - David Messika-Zeitoun
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| |
Collapse
|
13
|
Mestres CA. Native aortic valve regurgitation and transcatheter aortic valve replacement: a word of caution or still too early? Indian J Thorac Cardiovasc Surg 2024; 40:271-272. [PMID: 38389755 PMCID: PMC10879062 DOI: 10.1007/s12055-023-01678-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 02/24/2024] Open
Affiliation(s)
- Carlos A. Mestres
- Department of Cardiothoracic Surgery and The Robert WM Frater Cardiovascular Research Centre, The University of the Free State, PO Box 339 (Internal Box G32), Bloemfontein, 9300 South Africa
| |
Collapse
|
14
|
Noble S, Mauler-Wittwer S. TAVR as an Alternative to SAVR for Pure Native Aortic Regurgitation. Can J Cardiol 2024; 40:316-325. [PMID: 38016541 DOI: 10.1016/j.cjca.2023.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023] Open
Abstract
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 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 owing to excessive volume overload. It is often combined with a dilated aortic annulus and ascending aorta. Surgical aortic valve replacement remains the criterion 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 there are no anchoring points or 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 related to increased risk of paravalvular leak and 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.
Collapse
Affiliation(s)
- Stéphane Noble
- Structural Heart Unit, University Hospital of Geneva, Geneva, Switzerland.
| | | |
Collapse
|
15
|
SHEN H, FENG XX, GUO QY, ZHOU YJ. Updates of developments in interventional therapy for elderly patients with cardiovascular diseases. J Geriatr Cardiol 2024; 21:1-3. [PMID: 38440339 PMCID: PMC10908584 DOI: 10.26599/1671-5411.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Affiliation(s)
- Hua SHEN
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Beijing Institute of Heart Lung and Blood Vessel Disease, Clinical Center for Coronary Heart Disease, Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xun-Xun FENG
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Beijing Institute of Heart Lung and Blood Vessel Disease, Clinical Center for Coronary Heart Disease, Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qian-Yun GUO
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Beijing Institute of Heart Lung and Blood Vessel Disease, Clinical Center for Coronary Heart Disease, Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yu-Jie ZHOU
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Beijing Institute of Heart Lung and Blood Vessel Disease, Clinical Center for Coronary Heart Disease, Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
16
|
Khokhar AA, Curio J, Sticchi A, Hartley A, Demir OM, Ruparelia N. Transcatheter Aortic Valve Implantation to Treat Degenerated Aortic, Mitral and Tricuspid Bioprosthesis. J Clin Med 2024; 13:592. [PMID: 38276098 PMCID: PMC10816283 DOI: 10.3390/jcm13020592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/06/2024] [Accepted: 01/12/2024] [Indexed: 01/27/2024] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is now well established as the treatment of choice for patients with native aortic valve stenosis who are high or intermediate risk for surgical aortic valve replacement. Recent data has also supported the use of TAVI in patients at low surgical risk and also in anatomical subsets that were previously felt to be contra-indicated including bicuspid aortic valves and aortic regurgitation. With advancements and refinements in procedural techniques, the application of this technology has now been further expanded to include the management of degenerated bioprosthesis. After the demonstration of feasibility and safety in the management of degenerated aortic bioprosthetic valves, mitral and tricuspid bioprosthetic valve treatment is now also well-established and provides an attractive alternative to performing redo surgery. In this review, we appraise the latest clinical evidence and highlight procedural considerations when utilising TAVI technology in the management of degenerated aortic, mitral or tricuspid prosthesis.
Collapse
Affiliation(s)
- Arif A. Khokhar
- Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK; (A.A.K.); (A.H.)
| | - Jonathan Curio
- Department of Cardiology, Heart Center Cologne, Faculty of Medicine, University Hospital, University of Cologne, 50937 Cologne, Germany;
| | - Alessandro Sticchi
- Cardiac Catheterisation Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy;
- Università di Pisa, Lungarno Pacinotti 43, 56126 Pisa, Italy
| | - Adam Hartley
- Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK; (A.A.K.); (A.H.)
| | - Ozan M. Demir
- Department of Cardiology, Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon SS16 5NL, UK
| | - Neil Ruparelia
- Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK; (A.A.K.); (A.H.)
- Cardiology, Royal Berkshire Hospital, Reading RG1 5AN, UK
| |
Collapse
|
17
|
Ferrer-Sistach E, Teis A, Escabia C, Delgado V. Assessment of the Severity of Aortic Regurgitation by Noninvasive Imaging : Non-invasive MMI for AR. Curr Cardiol Rep 2024; 26:1-14. [PMID: 38091195 DOI: 10.1007/s11886-023-02011-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/27/2024]
Abstract
PURPOSE OF THE REVIEW The role of multimodality imaging in the evaluation of patients with aortic regurgitation is summarized in this review. RECENT FINDINGS The etiology (mechanism) of the aortic regurgitation and the severity of aortic regurgitation and hemodynamic consequences are key in the decision making of patients with severe aortic regurgitation. While echocardiography remains as the leading technique to assess all these parameters, other imaging techniques have become essential for the accurate assessment of aortic regurgitation severity and the timing of aortic intervention. The anatomic suitability of transcatheter aortic valve implantation in inoperable patients with severe aortic regurgitation is usually assessed with computed tomography. Aortic regurgitation is a prevalent disease with various pathophysiological mechanisms that need a personalized treatment. The evaluation of the mechanism and severity of aortic regurgitation can be initially performed with echocardiography. Three-dimensional techniques, including echocardiography, have become very relevant for accurate assessment of the regurgitation severity and its hemodynamic consequences. Assessment of myocardial tissue characteristics with cardiac magnetic resonance is key in the risk stratification of patients and in the timing of aortic intervention. Computed tomography is important in the assessment of aortic dimensions and selection of patients for transcatheter aortic valve implantation.
Collapse
Affiliation(s)
- Elena Ferrer-Sistach
- Heart Institute, University Hospital Germans Trias I Pujol, Carretera de Canyet S/N, 08916, Badalona, Spain
| | - Albert Teis
- Heart Institute, University Hospital Germans Trias I Pujol, Carretera de Canyet S/N, 08916, Badalona, Spain
| | - Claudia Escabia
- Heart Institute, University Hospital Germans Trias I Pujol, Carretera de Canyet S/N, 08916, Badalona, Spain
| | - Victoria Delgado
- Heart Institute, University Hospital Germans Trias I Pujol, Carretera de Canyet S/N, 08916, Badalona, Spain.
- Center for Comparative Medicine and Bioimaging (CMCIB), Germans Trias I Pujol Research Institute (IGTP), Badalona, Spain.
| |
Collapse
|
18
|
Narayan P. Native aortic valve regurgitation: TAVR's place in the PANTHEON. Indian J Thorac Cardiovasc Surg 2023; 39:643-645. [PMID: 37885937 PMCID: PMC10597891 DOI: 10.1007/s12055-023-01609-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 10/28/2023] Open
Abstract
The PANTHEON (Performance of Currently Available traNscaTHEter Aortic Valve Platforms in Inoperable Patients With Pure Aortic regurgitatiON of a native valve) study examined transcatheter aortic valve replacement in patients with severe pure native aortic valve regurgitation. With a real-world dataset from 16 centres in Europe and the USA, the study encompassed 201 patients. The major complications included valve embolization or migration in 12.4%, moderate to severe aortic regurgitation in 9.5% cases and need for permanent pacemaker in 22.3% cases. Self-expanding and balloon-expandable devices demonstrated similar outcomes. Those experiencing valve embolization or migration had higher 1-year adverse event rates.
Collapse
Affiliation(s)
- Pradeep Narayan
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, 124, EM Bypass, Mukundapur, Kolkata, 700099 India
| |
Collapse
|
19
|
Vora AN, Sreenivasan J, Forrest JK. Progressing Forward in Transcatheter Aortic Valve Replacement for Pure Aortic Regurgitation. JACC Cardiovasc Interv 2023; 16:1986-1989. [PMID: 37648346 DOI: 10.1016/j.jcin.2023.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/21/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Amit N Vora
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Jayakumar Sreenivasan
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John K Forrest
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|