Risk factors for paravalvular leak after transcatheter aortic valve replacement

Long-term follow-up of balloon-expandable valves according to the implantation strategy: insight from the DIRECTAVI trial

BACKGROUND

Safety and feasibility of transcatheter aortic valve replacement (TAVR) without balloon aortic valvuloplasty (BAV) using the SAPIEN 3 balloon-expandable device has been previously demonstrated. The impact on long-term valve hemodynamic performances and outcomes remains however unknown. We evaluate long-term clinical and hemodynamic results according to the implant strategy (direct TAVR vs BAV pre-TAVR) in patients included in the DIRECTAVI randomized trial (NCT02729519).

METHODS

Clinical and echocardiographic follow-up until January 2023 was performed for all patients included in the DIRECTAVI trial since 2016 (n = 228). The primary endpoint was incidence of moderate/severe hemodynamic valve deterioration (HVD), according to the Valve Academic Research defined Consortium-3 criteria (increase in mean gradient ≥10 mmHg resulting in a final mean gradient ≥20 mmHg, or new/worsening aortic regurgitation of 1 grade resulting in ≥ moderate aortic regurgitation).

RESULTS

Median follow-up was 3.8 (2.2-4.7) years. Mean age at follow-up was 87 ± 6.7 years. No difference in incidence of HVD in the direct implantation group compared to the BAV group was found (incidence of 1.97 per 100 person-years and 1.45 per 100 person-years, respectively, P = 0.6). Prevalence of predicted prothesis-patient mismatch was low (n = 13 [11.4%] in the direct TAVR group vs n = 15 [13.2%] in BAV group) and similar between both groups (P = .7). Major outcomes including death, stroke, hospitalization for heart failure and pacemaker implantation were similar between both groups, (P = .4, P = .7, P = .3, and P = .3 respectively).

CONCLUSION

Direct implantation of the balloon-expandable device in TAVR was not associated with an increased risk of moderate/severe HVD or major outcomes up to 6-year follow-up. These results guarantee wide use of direct balloon-expandable valve implantation, when feasible.

CLINICAL TRIALS REGISTRATION NUMBER

NCT05140317.

Complete transcatheter versus surgical approach to aortic stenosis with coronary artery disease: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to evaluate outcomes of transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) versus surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG).

METHODS

The MEDLINE, EMBASE, and Cochrane Library databases were searched through November 2021 to identify studies comparing TAVR + PCI and SAVR + CABG for severe aortic stenosis with concurrent coronary artery disease. Outcomes of interest were all-cause mortality, repeat coronary intervention, rehospitalization, myocardial infarction, and stroke during follow-up, and 30-day periprocedural outcomes.

RESULTS

Two randomized controlled trials and 6 observational studies including a total of 104,220 patients (TAVR + PCI, n = 5004; SAVR + CABG, n = 99,216) were included. The weighted mean follow-up period was 30.2 months. TAVR + PCI was associated with greater all-cause mortality and coronary reintervention during follow-up period (hazard ratio, 1.35; 95% confidence interval [CI], 1.11-1.65; P = .003, hazard ratio, 4.14; 95% CI, 1.74-9.86; P = .001, respectively), 30-day permanent pacemaker implantation rate (odds ratio [OR], 3.79; 95% CI, 1.61-8.95; P = .002), and periprocedural vascular complications (OR, 6.97; 95% CI, 1.85-26.30; P = .004). In contrast, TAVR + PCI was associated with a lower rate of 30-day acute kidney injury (OR, 0.32; 95% CI, 0.20-0.50; P = .0001). Rehospitalization, myocardial infarction, stroke during follow-up, and other periprocedural outcomes including 30-day mortality were similar in both groups.

CONCLUSIONS

In patients with severe aortic stenosis and coronary artery disease, TAVR + PCI was associated with greater all-cause mortality at follow-up compared with SAVR + CABG. Heart Team approach to assess TAVR candidacy remains imperative.

Intravascular lithotripsy (IVL) enabled the percutaneous closure of a severely calcified paravalvular leak regurgitation following implantation of a self-expandable transcatheter aortic valve: a case report

Background

Closure of paravalvular leak (PVL) regurgitation after self-expandable (SE) transcatheter aortic valve implantation (TAVI) may be more challenging than after balloon-expandable (BE) valve implantation.

Case summary

An 85-year-old woman suffering from long-standing atrial fibrillation and severe symptomatic aortic stenosis underwent SE TAVI (26 mm Evolut™ R®, Medtronic Inc., MN, USA). A total of eighteen months after TAVI she was admitted for congestive heart failure and two-dimensional (2D) transesophageal echocardiography (TEE) color Doppler showed moderate-severe PVL regurgitation due to a long and heavily calcified leak located below the left coronary sinus. The patient was deemed to be at prohibitive surgical risk and a catheter-based PVL closure procedure was planned. A first attempt to cross the PVL from the femoral artery was unsuccessful due to an inappropriate angle between the catheter and the entry site of this hard-to-approach calcified leak. A Terumo hydrophilic guidewire 0.35 inch-260 cm from the right radial artery was then successfully advanced across the leak to the left ventricle (LV); however, of most of the catheters used, only a Glidecath 4-Fr could cross the leak over the hydrophilic wire. The hydrophilic guidewire was replaced with a stiffer guidewire that, after creating a loop in the LV, was advanced across the self-expandable valve into the descending aorta where it was snared and externalized through the left femoral artery, thus creating an arterio-arterial (AA) loop. A 6-Fr Multipurpose guiding catheter was advanced over the exchange wire and the leak was crossed with an additional 0.0014 coronary guidewire (PILOT, Abbott Vascular), predilated with two non-compliant balloon dilatation catheters, and finally, the PVL was engaged with a 3.0 mm × 12 mm Shockwave balloon (Shockwave Medical Inc, Santa Clara, California, USA). Intravascular lithotripsy (IVL) application to this highly calcified leak and the increased support provided by the stiff guidewire finally allowed the progression of the 6-Fr dedicated delivery sheath (ODS III) into the LV. A 5 mm square twist (ST) device (PLD, Occlutech, Helsingborg, Sweden) was successfully deployed within the leak and the final echocardiographic and angiographic control confirmed the effective PVL closure.

Discussion

In patients at high surgical risk with moderate to severe regurgitation after SE TAVI due to a hard-to-approach calcified long tract, an extra AA support loop is mandatory during percutaneous PVL closure. Furthermore, IVL application greatly facilitates the progression of the delivery sheath and occluder which is key to a successful procedure.

Predictive Value of Aortic Valve Calcium Volume Measured by Computed Tomography for Paravalvular Leakage After Transcatheter Aortic Valve Implantation

Paravalvular leakage (PVL) is a complication of transcatheter aortic valve implantation (TAVI) for aortic stenosis, leading to an adverse prognosis. We investigated whether aortic valve calcium volume (Ca-Vol) measured by preoperative cardiac computed tomography had a predictive value for PVL after TAVI using a third-generation self-expandable valve.We retrospectively analyzed 59 consecutive patients who underwent TAVI using a third-generation self-expandable valve. We measured Ca-Vol in the aortic valve and each cusp (non-coronary cusp [NCC], right-coronary cusp [RCC], and left-coronary cusp [LCC]). We divided the patients into 2 groups: a PVL group (32.2%) and a non-PVL group (67.8%). Total Ca-Vol was significantly higher in the PVL group than in the non-PVL group (P < 0.001). Ca-Vol in each cusp was also significantly higher in the PVL group ([NCC] P < 0.001, [RCC] P = 0.001, [LCC] P < 0.001). Univariate logistic regression analysis for PVL indicated that the total and per-cusp Ca-Vols were predictors for PVL (total, odds ratio [OR] 4.0, P < 0.001; NCC, OR 12.5, P = 0.002; RCC, OR 16.0, P = 0.008; LCC, OR 44.5, P < 0.001).Receiver operating characteristic curve analysis of Ca-Vol for predicting PVL revealed the optimal cut-off values of Ca-Vol were 2.4 cm3 for the total, 0.74 cm3 for NCC, 0.73 cm3 for RCC, and 0.56 cm3 for LCC (area under the curve, 0.85, 0.79, 0.76, and 0.83, respectively).Preoperative total, NCC, RCC, and LCC calcium volumes were significant predictors for PVL after TAVI using third-generation self-expandable valves.

A systematic review of contrast-enhanced computed tomography calcium scoring methodologies and impact of aortic valve calcium burden on TAVI clinical outcomes

Different methodologies have been used to assess the role of AV calcification (AVC) on TAVI outcomes. This systematic review aims to describe the burden of AVC, synthesize the different methods of calcium score quantification, and evaluate the impact of AVC on outcomes after TAVI. We included studies of TAVI patients who had reported AV calcium scoring by contrast-enhanced multidetector CT and the Agatston method. The impact of calcification on TAVI outcomes without restrictions on follow-up time or outcome type was evaluated. Results were reported descriptively, and a meta-analysis was conducted when feasible. Sixty-eight articles were included, with sample sizes ranging from 23 to 1425 patients. Contrast-enhanced calcium scoring was reported in 30 studies, calcium volume score in 28 studies, and unique scoring methods in two. All studies with calcium volume scores had variable protocols, but most utilized a modified Agatston method with variable attenuation threshold values of 300-850 HU. Eight studies used the Agatston method, with the overall mean AV calcium score in studies published from 2010 to 2012 of 3342.9 AU [95%CI: 3150.4; 3535.4, I2 ​= ​0%]. The overall mean score was lower and heterogenous in studies published from 2014 to 2020 (2658.9 AU [95% CI: 2517.3; 2800.5, I2 ​= ​79%]. Most studies reported a positive association between calcium burden and increased risk of adverse outcomes, including implantation of permanent pacemaker (7/8 studies), paravalvular leak (13/13 studies), and risk of aortic rupture (2/2 studies). AVC quantification methodology with contrast-enhanced CT is still variable. AVC negatively impacts TAVI outcomes independently of the quantification method.

Results of new-generation balloon vs. self-expandable transcatheter heart valves for bicuspid aortic valve stenosis

Background

Data comparing new-generation self-expandable (SEV, Evolut R/PRO) vs. balloon-expandable (BEV, SAPIEN 3/3Ultra) transcatheter heart valve replacement (TAVR) in bicuspid aortic valve stenosis (BAV) is limited. Our aim was to compare 30-day results of SEV and BEV implantations in patients with BAV.

Methods

A total of 2009 patients underwent TAVR between April 2015 and June 2021 at our Centre. From our institutional registry, we identified 106 consecutive patients with BAV who underwent TAVR using SEV and BEV.

Results

A 106 patients (n = 68 BEV; n = 38 SEV) were included. Mean age was 74.6 ± 8.8 years (BEV) vs.75.3 ± 8.7 years (SEV) (p = 0.670) and Society of Thoracic Surgeons score was 2.6 ± 1.9 (BEV) vs. 2.6 ± 1.6 (SEV) (p = 0.374), respectively. Device landing zone calcium volume (DLZ-CV) was 1168 ± 811 vs. 945 ± 850 mm3 (p = 0.192). Valve Academic Research Consortium (VARC)-3 device success at 30 days was similar (BEV 80.9% vs. SEV 86.8%; p = 0.433). More post-dilatations were performed in SEVs (23.5% BEV vs. 52.6% SEV; p = 0.002). Overall mean gradient at 30 days follow-up was 11.9 ± 4.6 mmHG (BEV) vs. 9.2 ± 3.0 mmHG (SEV) (p = 0.002). A mild-moderate degree of paravalvular leak (PVL) was detected more often in the SEV group (7.4% vs. 13.2%; p = 0.305). A trend towards higher rate of permanent pacemaker implantation was observed in SEV (11.8% vs. 23.7%; p = 0.109).

Conclusions

Treatment of BAV revealed similar performance using BEV and SEV. In this retrospective cohort study, hemodynamics were more favorable with the SEV, although there was a trend toward more PVL and significantly more post-dilations.

A Machine Learning Model for the Accurate Prediction of 1-Year Survival in TAVI Patients: A Retrospective Observational Cohort Study

BACKGROUND

predicting the 1-year survival of patients undergoing transcatheter aortic valve implantation (TAVI) is indispensable for managing safe early discharge strategies and resource optimization.

METHODS

Routinely acquired data (134 variables) were used from 629 patients, who underwent transfemoral TAVI from 2012 up to 2018. Support vector machines, neuronal networks, random forests, nearest neighbour and Bayes models were used with new, previously unseen patients to predict 1-year mortality in TAVI patients. A genetic variable selection algorithm identified a set of predictor variables with high predictive power.

RESULTS

Univariate analyses revealed 19 variables (clinical, laboratory, echocardiographic, computed tomographic and ECG) that significantly influence 1-year survival. Before applying the reject option, the model performances in terms of negative predictive value (NPV) and positive predictive value (PPV) were similar between all models. After applying the reject option, the random forest model identified a subcohort showing a negative predictive value of 96% (positive predictive value = 92%, accuracy = 96%).

CONCLUSIONS

Our model can predict the 1-year survival with very high negative and sufficiently high positive predictive value, with very high accuracy. The "reject option" allows a high performance and harmonic integration of machine learning in the clinical decision process.

The Evolving Role of Surgical Aortic Valve Replacement in the Era of Transcatheter Valvular Procedures

Surgical aortic valve replacement (SAVR) has long been the standard treatment for severe symptomatic aortic stenosis (AS). However, transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative; it was initially intended for high-risk patients and has now expanded its use to patients of all risk groups. While TAVR has demonstrated promising outcomes in diverse patient populations, uncertainties persist regarding its long-term durability and potential complications, raising the issue of the ideal lifetime management strategy for patients with AS. Therefore, SAVR continues to play an important role in clinical practice, particularly in younger patients with longer life expectancies, those with complex aortic anatomy who are unsuitable for TAVR, and those requiring concomitant surgical procedures. The choice between TAVR and SAVR warrants personalized decision-making, considering patient characteristics, comorbidities, anatomical considerations, and overall life expectancy. A multidisciplinary approach involving an experienced heart team is crucial in the preoperative evaluation process. In this review, we aimed to explore the current role of surgical management in addressing aortic valve stenosis amidst the expanding utilization of less invasive transcatheter procedures.

Comparisons of different new-generation transcatheter aortic valve implantation devices for patients with severe aortic stenosis: a systematic review and network meta-analysis

BACKGROUND

Whether there are differences among the new-generation transcatheter aortic valve implantation (TAVI) devices for patients with aortic stenosis remains unclear. The aim of the study was to compare the efficiency and safety of different new-generation TAVI devices for patients with aortic stenosis.

MATERIALS AND METHODS

A comprehensive search of PubMed, Embase and Web of Science from their inception to 1 February 2022. Randomized clinical trials and observational studies that compared two or more different TAVI devices were enroled. Pairwise meta-analysis and frequentist network meta-analysis were conducted to pool the outcome estimates of interest.

RESULTS

A total of 79 studies were finally included. According to the surface under the cumulative ranking, the top two ranked valves for lower rates of events were as follows: direct flow medical (DFM) (4.6%) and Lotus (48.8%) for lower rate of device success; Sapien 3 (16.8%) and DFM (19.7%) for lower mortality; DFM (8.6%) and Sapien 3 (25.5%) for lower rates of stroke; Evolut (27.6%) and DFM (35.8%) for lower rates of major and life-threatening bleeding; Portico (22.6%) and Sapien 3 (41.9%) for lower rates of acute kidney injury; Acurate (8.6%) and DFM (13.2%) for lower rates of permanent pacemaker implantation; Lotus (0.3%) and Sapien 3 (22.7%) for lower rates of paravalvular leak; Evolut (1.4%) and Portico (29.1%) for lower rates of mean aortic valve gradients.

CONCLUSIONS

The findings of the present study suggested that the device success rates were comparable among these new-generation valves except for DFM. After excluding DFM, Sapien 3 might be the best effective for decreased mortality and stroke; Lotus might be the best effective for decreased paravalvular leak; Evolut might be the best effective for decreased major and life-threatening bleeding and mean aortic valve gradients; Acurate and Portico might be the best effective for decreased permanent pacemaker implantation and acute kidney injury, respectively.

Quantity and location of aortic valve calcification predicts paravalvular leakage after transcatheter aortic valve replacement: a systematic review and meta-analysis

Introduction

Transcatheter aortic valve replacement (TAVR) is the first-line treatment for patients with moderate-to-high surgical risk of severe aortic stenosis. Paravalvular leakage (PVL) is a serious complication of TAVR, and aortic valve calcification contributes to the occurrence of PVL. This study aimed to investigate the effect of location and quantity of calcification in the aortic valve complex (AVC) and left ventricular outflow tract (LVOT) on PVL after TAVR.

Method

We performed a systematic review and meta-analysis to evaluate the effect of quantity and location of aortic valve calcification on PVL after TAVR using observational studies from PubMed and EMBASE databases from inception to February 16, 2022.

Results

Twenty-four observational studies with 6,846 patients were included in the analysis. A high quantity of calcium was observed in 29.6% of the patients; they showed a higher risk of significant PVL. There was heterogeneity between studies (I2 = 15%). In the subgroup analysis, PVL after TAVR was associated with the quantity of aortic valve calcification, especially those located in the LVOT, valve leaflets, and the device landing zone. A high quantity of calcium was associated with PVL, regardless of expandable types or MDCT thresholds used. However, for valves with sealing skirt, the amount of calcium has no significant effect on the incidence of PVL.

Conclusion

Our study elucidated the effect of aortic valve calcification on PVL and showed that the quantity and location of aortic valve calcification can help predict PVL. Furthermore, our results provide a reference for the selection of MDCT thresholds before TAVR. We also showed that balloon-expandable valves may not be effective in patients with high calcification, and valves with sealing skirts instead of those without sealing skirts should be applied more to prevent PVL from happening.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=354630, identifier: CRD42022354630.

Outcomes of procedural complications in transfemoral transcatheter aortic valve replacement

OBJECTIVES

As the application of transcatheter aortic valve replacement (TAVR) expands, the longitudinal implications of periprocedural complications are increasingly relevant. We examine the influence of TAVR complications on midterm survival.

METHODS

Patients undergoing transfemoral TAVR at our institution between November 2011 and June 2018 were reviewed. Stroke severity was classified according to the National Institutes of Health stroke score. Kaplan-Meier analysis was used to assess survival, and a Cox proportional hazards model was created to examine independent associations with survival. The median follow-up time was 36 months for a total of 2789 patient-years.

RESULTS

Overall, 866 patients were included. The mean age was 80 ± 9.5 years and mean Society of Thoracic Surgeons score was 4.8% ± 2.7%. The mortality rate at 30-days was 2.8% and 11.8% at 1 year. In-hospital left bundle branch block and 30-day permanent pacemaker insertion occurred in 14.8% and 7.9%, respectively. Postprocedural greater-than-mild paravalvular leak was present in 4.4% and stroke occurred in 3.8% at 30-days. Greater-than-mild paravalvular leak was associated with decreased survival at 2 years (P = .02), but not at 5 years. Severe stroke was independently associated with decreased survival at 5 years (hazard ratio, 5.73; 95% confidence interval, 2.29-14.36; P ≤ .001); however, the effect of nonsevere stroke did not reach significance (hazard ratio, 1.69; 95% confidence interval, 0.82-3.47; P = .152).

CONCLUSIONS

Severe stroke was independently associated with decreased 5-year survival and initial risks associated with paravalvular leak may be attenuated over the midterm following transfemoral TAVR. Strategies to minimize the incidence of stroke and paravalvular leak must be prioritized to improve longitudinal outcomes after TAVR.

Ten years' experience with the sutureless aortic valve replacement: incidence and predictors for survival and valve durability at follow-up

OBJECTIVES

Aortic valve replacement with a sutureless prosthesis [sutureless aortic valve replacement (Su-AVR)] is an option for patients with severe aortic valve stenosis. However, data regarding long-term outcomes and prosthesis durability are still lacking.

METHODS

All consecutive patients who successfully underwent Su-AVR with the Perceval valve in our centre between 2010 and 2020 were included in the analysis and followed prospectively with echocardiography. Risk factor analysis was performed to assess variables associated with worse survival and bioprosthetic valve failure.

RESULTS

Study population consisted of 547 patients: the mean age was 76.4 (5.2) years, 51% were female and the mean logistic EuroSCORE was 13% (11). The median survival was 7.76 years [95% confidence interval (CI) = 6.9-8.6]. Risk factor analysis identified age [hazard ratio (HR) 1.06, 95% CI 1.03-1.11; P < 0.001), EuroSCORE II (HR 1.08, 1.02-1.13; P < 0.001), baseline dialysis (HR 2.14, 95% CI 1.4-4.4; P = 0.038) and postoperative acute kidney injury ≥2 (HR 8.97, 95% CI 4.58-17.6; P < 0.001) as factors significantly correlated with worse survival. The reported HRs for age are per 1 year and for EuroSCORE II is 1 percentage point. Structural valve deterioration (SVD) was observed in 23 patients, of whom 19 underwent reintervention (median freedom from SVD 10.3 years). In multivariable Cox analysis, age (HR 0.89, 95% CI 0.82-0.95; P < 0.001) was found to be a significant predictor of SVD. Overall, 1.8% was referred for prosthetic valve endocarditis (confirmed or suspected) during follow-up. One patient showed moderate non-SVD and none developed prosthetic valve thrombosis.

CONCLUSIONS

The sutureless valve represents a reliable bioprosthesis for aortic valve replacement in patients with a 10-year life expectancy. Younger age at the time of implant is the only factor associated with the risk of long-term SVD.

Regional Variation in the Use and Outcomes of Transcatheter Aortic Valve Replacement in California

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has been widely adopted for management of aortic stenosis. The purpose of this study was to examine regional access to and outcomes following TAVR in California.

METHODS

Patients undergoing TAVR or isolated surgical aortic valve replacement (SAVR) from 2008 to 2019 in California were identified in the Office of Statewide Health Planning and Development database. California was divided into seven regions: Northern California, San Francisco Bay Area, Central California, Los Angeles, Inland Empire, Orange, and San Diego. Regional TAVR volumes were normalized to Medicare beneficiaries or isolated SAVR volume. Outcomes included risk-adjusted 30-day mortality and major adverse cardiovascular and cerebral events (MACCE). Trends were studied using non-parametric tests, and regional outcomes using logistic regression.

RESULTS

TAVR volume increased annually since 2011, with 7148 cases performed in California in 2019. After normalization, variation in utilization of TAVR was evident, with the least performed in Central California. TAVR to SAVR ratios in 2019 were greatest in Northern California, Los Angeles, and San Diego, and least in the Inland Empire. After risk adjustment, there were no significant regional differences in 30-day mortality, but lower 30-day MACCE in the San Francisco Bay Area.

CONCLUSIONS

Regional differences in TAVR utilization exist, with limited access in Central California and the Inland Empire, but risk-adjusted outcomes are similar. Efforts to reach underserved areas through existing program expansion or regional referrals may distribute transcatheter technology more equitably across California.

Post-Dilatation of New-Generation Self-Expandable Transcatheter Aortic Valves Does Not Increase Atrioventricular Conduction Abnormalities

The impact that post-dilatation has on the risk of experiencing conduction disorders after post-transcatheter aortic valve replacement with self-expanding valves (SE-TAVR) is unclear. We compared the rate of developing an atrioventricular (AV) high-grade conduction disorder and permanent pacemaker implantation (PPI) in post-TAVR patients undergoing post-dilatation. We enrolled patients with severe symptomatic calcified aortic stenosis (CAS) who were undergoing SE-TAVR between 1 January 2016, and 19 April 2019 at a single French center. Of the 532 patients treated with SE-TAVR, 417 subjects (78.4%) received Corevalve Evolute R and 115 subjects (21.6%) received the latest-generation Corevalve Evolute Pro valve. In total, 104/532 patients (19.5%; 21.6% with Evolute R vs. 12.2% with Evolute Pro, p = 0.024) required post-dilatation. Evolut R was associated with an increased risk of post-dilatation (odds ratio 2.1 (1.01-4.33, p = 0.046)). We did not observe any post-dilatation increases in AV or in intra- and interventricular conduction disorders. In total, 26.1% of participants needed PPI within the first 30 post-procedure days (p = 0.449). Post-dilatation was not associated with a higher PPI risk (subdistribution hazard ratio 1.033 (0.726-1.471); p = 0.857). No significant differences existed between the groups in terms of one-year mortality (10.3%; p = 0.507). Post-dilatation in SE-TAVR did not increase the rate of electrical conduction disorders and PPI in the early implantation phase. The latest generation of SE-TAVR valves was associated with less need for post-dilatation.

Prosthetic Valve Function after Aortic Valve Replacement for Severe Aortic Stenosis by Transcatheter Procedure versus Surgery

Background This study compared the clinical outcomes of transcatheter (TAVR) and surgical (SAVR) aortic valve replacements, focusing on postoperative valvular performance assessed by echocardiography. Method and Results A total of 425 patients who underwent TAVR (230 patients) or SAVR (195 patients) were included. Postoperative effective orifice area index (EOAI) was higher in the TAVR group (1.27 ± 0.35 cm2/m2) than in the SAVR group (1.06 ± 0.27 cm2/m2, p < 0.001), and patient−prosthesis mismatch (PPM) was more frequent in the SAVR group (22.6%) than in the TAVR group (8.7%, p < 0.001). Mild or greater paravalvular leakage (PVL) was more frequent in the TAVR group (21.3%) than in the SAVR group (0%, p < 0.001). Moreover, there was no difference in freedom from all-cause death, stroke, or rehospitalization between the groups. Patients with moderate or greater PPM (EOAI < 0.85 cm2/m2) had lower freedom from composite events than those without this PPM criterion (p = 0.008). Patients with mild or greater PVL also had lower freedom from composite events than those without this PVL criterion (p = 0.017). Conclusions Postoperative valvular performance of TAVR was superior to that of SAVR in terms of EOAI. This merit was counterbalanced by the significantly lower rates of PVL in patients who underwent SAVR. The overall clinical outcomes were similar between the study groups.

Paravalvular Leakages after Surgical Aortic-Valve Replacement and after Transcatheter Aortic-Valve Implantation: Strategies to Increase the Success Rate of Percutaneous Closure

Moderate to severe paravalvular-leak (PVL) regurgitation after surgical aortic-valve replacement or after transcatheter valve implantation represents a well-known complication associated with symptoms related to heart failure, hemolysis, or both in patients with multiple comorbidities and with poor prognostic outcomes. The transcatheter closure of aortic paravalvular leaks (APVLs) is currently considered a valid alternative to cardiac surgery. Nevertheless, careful patient selection, optimal cardiac imaging for intraprocedural guidance, and expert operators are key for success. Although technically demanding, particularly in APVLs after transcatheter valve implantation, catheter-based closure is an effective, less invasive, and often the only option for high-risk patients with symptomatic PVL regurgitation.

Risk of conduction disturbances following different transcatheter aortic valve prostheses: the role of aortic valve calcifications

OBJECTIVES

To assess the impact of prosthesis choice and aortic valve calcifications on the occurrence of conduction disturbances after transcatheter aortic valve implantation (TAVI).

METHODS

We retrospectively analyzed the preoperative clinical characteristics, electrocardiograms, contrast-enhanced multidetector computed tomography scans and procedural strategies of patients who underwent TAVI in our center between January 2012 and June 2017. Quantification of calcium volume was performed for each aortic cusp above (aortic valve) and below (left ventricular outflow tract, LVOT) the basal plane. Multivariate analysis was performed to evaluate risk factors for the onset of new bundle branch block (BBB), transient and permanent atrioventricular block (tAVB, pAVB).

RESULTS

A total of 569 patients were included in the study. Six different prostheses were implanted (Edwards Sapien XT, n = 162; Edwards Sapien 3, n = 240; Medtronic CoreValve, n = 27; Medtronic CoreValve Evolut R, n = 21; Symetis Acurate, n = 56; Symetis Acurate neo, n = 63). The logistic regression analysis for BBB showed association with baseline left anterior hemiblock. The logistic regression for tAVB, found the prior valvuloplasty and the balloon post-dilatation associated with the outcome. Baseline left and right BBB, degree of oversizing, and LVOT calcification beneath the non-coronary cusp were associated with pAVB. Neither the prosthesis model, nor the use of a self-expandable prosthesis showed statistical significance with the above-mentioned outcomes on univariate analysis.

CONCLUSIONS

LVOT calcification beneath the non-coronary cusp, baseline left anterior hemiblock, right BBB, balloon post-dilatation, prior valvuloplasty and oversizing are independently associated with postprocedural conduction disturbances after TAVI. Use of a self-expandable prosthesis may show a lower incidence of AVB, if applied in lower calcified aortic valves.

Cardiac Computed Tomography: Application in Valvular Heart Disease

The incidence and prevalence of valvular heart disease (VHD) is increasing and has been described as the next cardiac epidemic. Advances in imaging and therapeutics have revolutionized how we assess and treat patients with VHD. Although echocardiography continues to be the first-line imaging modality to assess the severity and the effects of VHD, advances in cardiac computed tomography (CT) now provide novel insights into VHD. Transcatheter valvular interventions rely heavily on CT guidance for procedural planning, predicting and detecting complications, and monitoring prosthesis. This review focuses on the current role and future prospects of CT in the assessment of aortic and mitral valves for transcatheter interventions, prosthetic valve complications such as thrombosis and endocarditis, and assessment of the myocardium.

Paravalvular Leak After Transcatheter Aortic Valve Implantation Its Incidence, Diagnosis, Clinical Implications, Prevention, Management, and Future Perspectives: A Review Article

Paravalvular leak (PVL) is very common after TAVI and has been reported to have a negative impact on both short- and long-term survival. The current study identified incidence, diagnosis, clinical implications, and prevention, management and future perspectives for post-TAVI paravalvular leak. A systematic literature search was conducted using PubMed and EMBASE, using the MeSH terms and key words "paravalvular leak," "diagnostic criteria," "implication," "influencing factors," and "prevention strategies." Studies were retained for review after meeting strict inclusion criteria that included only prospective studies evaluating Paravalvular leak in patients who had TAVI. Thirty articles were selected for inclusion, incidence of PVL across the studies ranged from 7% to 40%. Many factors have been associated with incidence and increased risk of PVL, including AVC volume, larger annulus dimensions, pre-TAVI transvalvular peak velocity, under sizing of the prosthesis, surgical, and other factors. PVL after TAVI is common and can be predicted by aortic root calcification volume, larger annulus dimensions, and pre-TAVI transvalvular peak velocity, with calcification volume being an independent predictor for PVL. The strength and nature of the association of various degrees of post-TAVI PVL and mortality are still to be further evaluated.

How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement

PURPOSE OF REVIEW

In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications.

RECENT FINDINGS

Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.

The Impact of Aortic Valvular Calcium on Transcatheter Heart Valve Distortion

Objectives

To investigate the relationship between the eccentric calcification of aortic valve and transcatheter heart valve (THV) distortion and the impact of THV distortion on echo parameters and clinical outcomes.

Background

The effects of eccentric calcification of the aortic valve on the THV distortion and the relationship between THV distortion and clinical impact were not fully understood.

Methods

Patients with symptomatic severe aortic stenosis who were undergoing THV implantation were enrolled. Patients underwent preprocedural, postprocedural multislice computed tomography (MSCT), and follow-up transthoracic echocardiogram (TTE). Delta calcium score (ΔCS) is defined as the difference between the maximum and minimal calcium scores of the three cusps, while valve distortion score (VDS) is defined as the difference between the longest and shortest stent frame, as obtained using MSCT. Patients were divided into two groups according to ΔCS: “noneccentric calcification group” and “eccentric calcification group.”

Results

A total of 118 patients were enrolled (59 patients in noneccentric and 59 in eccentric calcification groups). VDS was significantly lower in the noneccentric calcification group than in the eccentric calcification group (1.31 ± 0.82 mm vs. 1.73 ± 0.76 mm, p=0.004). VDS was not associated with the degree of paravalvular leak (PVL) and aortic valvular mean pressure gradient (AVPG) at 30-day and 1-year follow-up TTE and the cumulative rates of all-cause death and rehospitalization at 2-year clinical follow-up.

Conclusions

Eccentric valvular calcification was associated with longitudinal THV distortion. However, THV distortion was not associated with PVL, AVPG, and adverse clinical events during midterm follow-up.

Optimal Oversizing Index Depending on Valve Type and Leakage-Proof Function for Preventing Paravalvular Leakage after Transcatheter Aortic Valve Implantation

Paravalvular leak (PVL) is an important complication of transcatheter aortic valve implantation (TAVI) and is associated with poor prognosis. We aimed to identify the risk factors for PVL after TAVI including patient (calcium amount or location), device (leakage-proof or not), and procedural (oversizing index (OI)) factors. The primary outcome was mild or greater PVL at 1-month follow-up echocardiography. Overall, 238 patients who underwent TAVI using eight types of valves (Edwards Sapien, Sapien XT, Sapien 3, CoreValve, Evolut R, Evolut PRO, Lotus, and Lotus Edge) were included. The incidence of significant PVL (≥mild PVL) was 24.4%. Although patient factors (calcification of valve) were not predictors of PVL, valve without leakage-proof function (Edwards Sapien, Sapien XT, and CoreValve) was a significant predictor of PVL (adjusted odds ratio, 3.194, 95% CI, 1.620–6.299). Furthermore, OI has a significant protective role against PVL (PVL increased by 45% when OI decreased by 5%). The best cutoff value of OI to predict the absence of PVL was ≥17.6% for the Evolut system and ≥10.2% for the Sapien system. The predictors of PVL after TAVI included factors from the device (valve without leakage-proof function) and procedure (under-sizing). In patients with a high risk of PVL, the procedure should be optimized using valves with leakage-proof function and adequate OI.

Redo aortic valve replacement for prosthesis endocarditis in patients previously classified as high or prohibitive risk: a narrative review

Transcatheter aortic valve implantation (TAVI) and sutureless aortic valve replacement (Su-AVR) enabled in the last years many patients at high or prohibitive risk to be treated for their severe symptomatic aortic valve stenosis. As often happens in medicine, new techniques bring not only new hopes, but also new problems. In recent years, alongside the lengthening of the life of these patients treated with TAVI or Su-AVR, cardiologists and cardiac surgeons have had to face the long-term complications associated with the implantation of these devices, such as the prosthetic infective endocarditis. The correct management of prosthesis valve endocarditis after TAVI or Su-AVR in high risk patients, and the possible role of surgery are a matter of debate because pushing the limits of the modern medicine and becoming a new challenge for cardiac surgeons of 21^st century. In this review, we summarized the incidence, characteristics and evidences for this new and controversial problem of the cardiovascular community. Moreover, we investigated the outcomes reported in literature of the conservative and the surgical strategy. Although the reported mortality rate of surgical treatment is high, seems not prohibitive, mostly if compared to conservative medical therapy. The collaborative exchange between cardiologist, cardiac surgeons, clinical microbiologists and expert of imaging is mandatory to face this challenge.

Expansion of TAVR into Low-Risk Patients and Who to Consider for SAVR

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis (AS) over the last decade. The results of the Placement of Aortic Transcatheter Valves (PARTNER) 3 and Evolut Low Risk trials demonstrated the safety and efficacy of TAVR in low-surgical-risk patients and led to the approval of TAVR for use across the risk spectrum. Heart teams around the world will now be faced with evaluating a deluge of younger, healthier patients with severe AS. Prior to the PARTNER 3 and Evolut Low Risk studies, this heterogenous patient population would have undergone surgical aortic valve replacement (SAVR). It is unlikely that TAVR will completely supplant SAVR for the treatment of severe AS in patients with a low surgical risk, as SAVR has excellent short- and long-term outcomes and years of durability data. In this review, we outline the critical role that SAVR will continue to play in the treatment of severe AS in the post-PARTNER 3/Evolut Low Risk era.

Transcatheter aortic valve replacement: potential use in lower-risk aortic stenosis

INTRODUCTION

The widespread use of transcatheter aortic valve implantation (TAVI) is expanding to low-risk patients. Nevertheless, a low clinical risk does not always correspond to a low procedural risk for the percutaneous approach.

AREAS COVERED

The initial trials on TAVI in low-risk populations had encouraging results, showing non-inferiority in comparison to surgical aortic valve replacement (SAVR). However, the low-risk definition is based on risk score calculators developed for the surgical setting and not including other specific features that are more relevant to TAVI and can affect procedural outcomes. For example, the presence of bicuspid aortic valves, high calcific burden, low coronary height or conduction disturbances is all potentially associated with suboptimal results or even procedural complications. In addition, the lack of longer follow-up prevents us to draw conclusions about long-term outcomes, including data about valve durability and coronary re-access.

EXPERT OPINION

Although current evidence suggest similar results for TAVI and SAVR in low-risk populations, there are some technical and procedural limitations that still need to be addressed in order to close the gap between TAVI and surgery. Optimal, lasting results with a low rate of procedural complications are highly expected in low-risk, otherwise healthy subjects, with potential for longevity.

Aortic valve calcification as a risk factor for major complications and reduced survival after transcatheter replacement

BACKGROUND

Aortic valve calcification is supposed to be a possible cause of embolic stroke or subclinical valve thrombosis after transcatheter aortic valve replacement (TAVR). We aimed to assess the role of aortic valve calcification in the occurrence of in-hospital clinical complications and survival after TAVR.

METHODS

We retrospectively analyzed preoperative contrast-enhanced multidetector computed tomography scans of patients who underwent TAVR on the native aortic valve in our center. Calcium volume was calculated for each aortic cusp, above and below the aortic annulus. Outcomes were recorded according to VARC-2 criteria.

RESULTS

Overall, 581 patients were included in the study (SapienXT = 192; Sapien3 = 228; CoreValve/EvolutR = 45; Engager = 5; Acurate = 111). Median survival was 4.98 years (interquartile range 4.41-5.54). Logistic regression identified calcium load beneath the right coronary cusp in left ventricular outflow tract (LVOT) as significantly associated with stroke (odds ratio [OR] 1.2; 95% confidence interval [CI] 1.03-1.3; p = 0.0019) and in-hospital mortality (OR 1.1; 95% CI 1.004-1.2; p = 0.04), whereas total calcium volume of the LVOT was associated with both in-hospital and 30 day-mortality (OR 1.2; 95% CI 1.01-1.4; p = 0.03, and OR 1.2; 95% CI 1.02-1.43; p = 0.029, respectively). Cox regression identified total calcium of LVOT (hazard ratio [HR] 1.18; 95% CI 1.02-1.38; p = 0.026), male sex (HR 1.88; 95% CI 1.06-3.32; p = 0.031), baseline creatinine clearance (HR 0.96; 95% CI 0.93-0.98; p < 0.001), and baseline severe aortic regurgitation (HR 7.48; 95% CI 2.76-20.26; p < 0.001) as risk factors associated with lower survival.

CONCLUSION

LVOT calcification is associated with increased risk of peri-procedural stroke and mortality as well as shorter long-term survival.

Transcatheter, sutureless and conventional aortic-valve replacement: a network meta-analysis of 16,432 patients

Background

Minimally invasive surgical techniques pose alternatives to conventional surgery for the treatment of aortic stenosis (AS). We present a Bayesian network analysis comparing Valve Academic Research Consortium-2 clinical outcomes between transcatheter aortic valve implantation (TAVI), sutureless (SL-AVR) and conventional aortic valve replacement (CAVR).

Methods

Electronic searches of databases were conducted and seven two-arm randomized-controlled trials and 25 propensity-score-matched studies comparing clinical outcomes of TAVI, SL-AVR and CAVR for treatment of AS were identified. Bayesian Markov chain Monte Carlo modelling was used to analyze clinical outcomes.

Results

The analysis included 16,432 patients who underwent TAVI [7,056], SL-AVR [1,238] or CAVR [8,138]. Compared to CAVR, TAVI and SL-AVR were associated with reduced postoperative major bleeding of 59% (OR 0.41, 95% CI: 0.28-0.59) and 44% (OR 0.56, 95% CI: 0.30-0.99) respectively. TAVI had a 41% reduction in postoperative myocardial infarction (OR 0.59, 95% CI: 0.40-0.86) and SL-AVR had a 40% reduction in postoperative acute kidney injury (AKI) (OR 0.62, 95% CI: 0.42-0.86). Compared to TAVI, CAVR and SL-AVR had a reduction in moderate/severe paravalvular regurgitation of 89% (OR 0.11, 95% CI: 0.07-0.16) and 92% (OR 0.08, 95% CI: 0.03-0.17). CAVR had a 67% decreased postoperative permanent pacemaker (PPM) implantation compared to TAVI (OR 0.33, 95% CI: 0.24-0.45) and a 63% reduction compared to SL-AVR (OR 0.37, 95% CI: 0.22-0.61). There were no differences in 30-day mortality or postoperative stroke between the groups.

Conclusions

In selected patients, minimally invasive surgical interventions including TAVI and SL-AVR for severe AS are viable alternatives to conventional surgery. However, TAVI is associated with increased paravalvular regurgitation, whereas TAVI and SL-AVR are associated with increased conduction disturbances compared to CAVR.