Beyond Indications

Comparison of the investigational device exemption and post-approval trials of the Melody transcatheter pulmonary valve

OBJECTIVE

We compared 5-year outcomes of transcatheter pulmonary valve (TPV) replacement with the Melody TPV in the post-approval study (PAS) and the investigational device exemption (IDE) trial.

BACKGROUND

As a condition of approval of the Melody TPV after the IDE trial, the Food and Drug Administration required that a PAS be conducted to evaluate outcomes of TPV replacement in a "real-world" environment. The 5-year outcomes of the PAS have not been published, and the IDE and PAS trials have not been compared.

METHODS

The cohorts comprised all patients catheterized and implanted at 5 IDE sites and 10 PAS sites. Differences in trial protocols were detailed. Time-related outcomes and valve-related adverse events were compared between the two trials with Kaplan-Meier curves and log-rank testing.

RESULTS

167 patients (median age, 19 years) were catheterized and 150 underwent TPV replacement in the IDE trial; 121 were catheterized (median age, 17 years) and 100 implanted in the PAS. Freedom from hemodynamic dysfunction (p = .61) or any reintervention (p = .74) over time did not differ between trials. Freedom from stent fracture (p = .003) and transcatheter reintervention (p = .010) were longer in PAS, whereas freedom from explant (p = .020) and TPV endocarditis (p = .007) were shorter. Clinically important adverse events (AEs) were reported in 14% of PAS and 7.2% of IDE patients (p = .056); the incidence of any particular event was low in both.

CONCLUSIONS

Hemodynamic and time-related outcomes in the PAS and IDE trials were generally similar, confirming the effectiveness of the Melody TPV with real-world providers. There were few significant complications and limited power to identify important differences in AEs. The lack of major differences in outcomes between the two studies questions the usefulness of mandated costly post-approval studies as part of the regulatory process for Class III medical devices.

Outcomes Associated with the Off-label Use of Medical Devices in Congenital Heart Disease at a Single Institute

Background and Objectives

While the off-label use of implantable medical devices for treating congenital heart disease is not uncommon, the present conditions and outcomes of their off-label use have rarely been described. Therefore, this study evaluated the prevalence and results of using implantable devices off-label to treat congenital heart disease at a single institute.

Subjects and Methods

This was a retrospective study based on the medical records of catheter-based interventions for congenital heart disease performed from July 1, 1995 to June 1, 2015. The inclusion criterion was the off-label use of an implantable device. Patient demographic data, procedural success, and follow-up status regarding late complications were investigated, and the results of the off-label use of each device were compared.

Results

Off-label use occurred in 144 of 1730 interventions with device implantation, accounting for 8.3% of the interventions. The median patient age and mean body weight were 51.0 months and 16.3 kg, respectively. Immediate and late failures were found in 9 cases, and 3 cases of mortality were not directly related to the devices used. The overall success rate was 93.8%. There were no long-term complications of the off-label use of occlusion devices. No procedural failures resulted from stent implantation, but one case of stent malposition and two cases of stent fracture were identified after procedure completion.

Conclusion

In general, the off-label use of implantable devices for treating congenital heart disease is safe and effective.

In vitro hemodynamic testing of Amplatzer plugs for paravalvular leak occlusion after transcatheter aortic valve implantation

OBJECTIVE

We aimed to in-vitro test Amplatzer devices (Amplatzer Vascular Plug II and Amplatzer Vascular Plug III, SJM, St. Paul, MN) in closing PVL generated by transcatheter balloon expandable aortic valve prosthesis in order to quantify the effective treatment of PVL.

BACKGROUND

Transcatheter aortic valve implantation (TAVI) procedures represent the treatment of choice for high risk patients. Despite evolving technologies paravalvular leak (PVL) is still a major unaddressed issue. This severe complication significantly impairs long-term survival. Percutaneous treatment of this complication is usually performed with the implantation of not specifically designed and not approved vascular devices.

METHODS

A 26 mm Sapien XT (Edwards Lifesciences, Irvine, CA) was implanted in a rubber aortic root and a semi-elliptical shape PVL was created. The vascular occluder devices were implanted in the PVL and hemodynamic performance was tested in a pulse duplicator according to international standard ISO 5840-3:2013. Different type of comparison tests together with high speed camera recording allowed us to define the global efficiency of the occluders and their interaction with the transcatheter prosthesis.

RESULTS

The results revealed that the use of vascular plugs was not per se sufficient to produce an effective or substantial reduction of PVL with a maximum efficiency of less than 50%. Recorded video showed clearly that the vascular plug always interfered with the leaflet of the prosthetic valve.

CONCLUSIONS

Currently used devices do not guarantee effective treatment of PVL and may otherwise compromise the structural integrity of the prosthetic valve implanted. Specifically designed devices are required.

CONDENSED ABSTRACT

Despite evolving technologies, paravalvular leak (PVL) is still a major unaddressed issue after transcatheter aortic valve implantation. Percutaneous treatment of this complication is usually performed with the implantation of Amplatzer devices not specifically designed and not approved for this specific use. We tested Amplatzer devices in a pulse duplicator to occlude PVL generated after implantation of a 26 mm SAPIENT XT prosthesis. The results revealed that the use of vascular plugs was not per se sufficient to produce an effective or substantial reduction of PVL. The video showed clearly that the vascular plug always interfered with the leaflet of the prosthetic valve.

The hybrid tracheoesophageal puncture procedure: indications and outcomes

OBJECTIVES

This report aimed to describe a novel and efficient method of tracheoesophageal puncture using a hybrid device assembled from 2 commercially available puncture kits; to demonstrate the utility of this technique in the performance of primary and secondary procedures, under general and local anesthesia, with and without flap reconstruction; and to evaluate the efficacy of concurrent puncture and valve placement.

METHODS

Thirty-four patients who underwent either primary or secondary tracheoesophageal puncture for voice restoration. Charts were reviewed retrospectively for complications, time to first valve change, operative time, and blood loss.

RESULTS

Using this novel hybrid device, simultaneous puncture and valve placement was achieved in 34 consecutive patients. There was 1 major complication; blood loss was negligible; and the procedure could be accomplished in all cases. There were no cases of prosthesis failure as a result of the insertion technique.

CONCLUSION

Concurrent tracheoesophageal puncture and voice prosthesis placement is a simple and efficient method of voice restoration in the laryngectomized patient and can be more easily accomplished with a hybrid device assembled from the components of 2 commercially available puncture kits. It can be performed under local as well as general anesthesia. The procedure is adaptable to a variety of clinical situations.