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Kherallah RY, Suffredini JM, Rahman F, Eng MH, Kleiman N, Manandhar P, Kosinski A, Silva G, Kamat I, Kapadia S, Vemulapalli S, Jneid H. Impact of Elevated Gradients After Transcatheter Aortic Valve Implantation for Degenerated Surgical Aortic Valve Bioprostheses. Circ Cardiovasc Interv 2024; 17:e013558. [PMID: 38785079 DOI: 10.1161/circinterventions.123.013558] [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: 08/26/2023] [Accepted: 03/18/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Elevated aortic valve gradients are common after transcatheter aortic valve implantation for degenerated surgical aortic valve replacement bioprostheses, but their clinical impact is uncertain. METHODS A total of 12 122 patients who underwent transcatheter aortic valve implantation-in-surgical aortic valve replacement from November 2011 to December 2019 in the Society of Thoracic Surgery/American College of Cardiology Transvalvular Therapeutics Registry were included. The primary outcome was a composite of 1-year all-cause mortality, stroke, myocardial infarction, or valve reintervention. Secondary outcomes included 1-year all-cause mortality, readmission, and change from baseline 12-question self-administered Kansas City Cardiomyopathy Questionnaire-Overall Summary Score. Due to nonlinearity observed with restricted cubic splines analysis, a Cox regression analysis with aortic valve mean gradient modeled as a spline-continuous variable (with 20 mm Hg as a cutoff) was used to study the 1-year composite outcome and mortality. RESULTS The composite outcome occurred most frequently in patients with aortic valve mean gradient ≥30 and <10 mm Hg, as compared with those with 10 to 20 and 20 to 30 mm Hg ranges (unadjusted rates, 13.9%, 12.1%, 7.5%, and 6.5%, respectively; P=0.002). When the mean aortic valve gradient was ≥20 mm Hg, higher gradients were associated with greater risk of the 1-year composite outcome (adjusted hazard ratio, 1.02 [1.02-1.03] per mm Hg; P<0.001) and 1-year mortality (adjusted hazard ratio, 1.02 [1.00-1.03] per mm Hg; P=0.007). Whereas when the mean aortic valve gradient was <20 mm Hg, higher gradients were not significantly associated with the composite outcome (adjusted hazard ratio, 0.99 [0.98-1.003] per mm Hg; P=0.12) but were associated with lower 1-year mortality (adjusted hazard ratio, 0.98 [0.97-0.99] per mm Hg; P=0.007). CONCLUSIONS The relationship between postprocedural aortic valve mean gradient after transcatheter aortic valve implantation-in-surgical aortic valve replacement and clinical outcomes is complex and nonlinear, with relatively greater adverse events occurring at low and high gradient extremes. Further study of factors mediating the relationship between postprocedural gradients and clinical outcomes, including low-flow states, is necessary.
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Affiliation(s)
- Riyad Yazan Kherallah
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (R.Y.K., J.M.S., G.S.)
| | - John M Suffredini
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (R.Y.K., J.M.S., G.S.)
| | - Faisal Rahman
- Division of Cardiology, Department of Medicine, John Hopkins School of Medicine, Baltimore, MD (F.R.)
| | - Marvin H Eng
- Division of Cardiology, Department of Internal Medicine, University of Arizona Banner University Heart Institute, Phoenix (M.H.E.)
| | - Neal Kleiman
- Department of Cardiology, Houston Methodist Hospital, TX (N.K.)
| | | | | | - Guilherme Silva
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (R.Y.K., J.M.S., G.S.)
| | - Ishan Kamat
- Division of Cardiology, Department of Internal Medicine, University of California San Francisco (I.K.)
| | - Samir Kapadia
- Department of Internal Medicine, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, OH (S.K.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, NC (P.M., A.K., S.V.)
- Division of Cardiology, Department of Internal Medicine, Duke Department of Medicine, Durham, NC (S.V.)
| | - Hani Jneid
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston (H.J.)
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Bartos PV, Molnar B, Herold Z, Dekany G, Piroth Z, Horvath G, Ahres A, Heesch CM, Czobor NR, Satish S, Pinter T, Fontos G, Andreka P. Short- and Medium-Term Outcomes Comparison of Native- and Valve-in-Valve TAVI Procedures. Rev Cardiovasc Med 2023; 24:255. [PMID: 39076381 PMCID: PMC11270067 DOI: 10.31083/j.rcm2409255] [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: 02/28/2023] [Revised: 07/01/2023] [Accepted: 07/21/2023] [Indexed: 07/31/2024] Open
Abstract
Background In high-risk patients with degenerated aortic bioprostheses, valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a less invasive alternative to surgical valve replacement. To compare outcomes of ViV and native valve (NV) TAVI procedures. Methods 34 aortic ViV-TAVI performed between 2012 and 2022 using self-expanding valves, were included in this retrospective analysis. Propensity score matching (1:2 ratio, 19 criteria) was used to select a comparison NV-TAVI group from a database of 1206 TAVI procedures. Clinical and echocardiographic endpoints, short- and long-term all-cause mortality (ACM) and cardiovascular mortality (CVM) data were obtained. Subgroup analyses were completed according to the true internal diameter, dividing patients into a small ( ≤ 19 mm) valve group (SVG) and a large ( > 19 mm) valve group (LVG). Results Clinical outcomes of ViV- and NV-TAVI were comparable, including device success [88.2% vs. 91.1%, p = 0.727], major adverse cardiovascular and cerebrovascular events [5.8% vs. 5.8%, p = 1.000], hemodialysis need [5.8% vs. 2.9%, p = 0.599], pacemaker need [2.9% vs. 11.7%, p = 0.265], major vascular complications [2.9% vs. 1.4%, p = 1.000], life-threatening or major bleeding [2.9% vs. 1.4%, p = 1.000] and in-hospital mortality [8.8% vs. 5.9%, p = 0.556]. There was a significant difference in the immediate post-intervention mean residual aortic valve gradient (MAVG) [14.6 ± 8.5 mm Hg vs. 6.4 ± 4.5 mm Hg, p < 0.0001], which persisted at 1 year [p = 0.0002]. There were no differences in 12- or 30-month ACM [11.8% vs. 8.8%, p = 0.588; 23.5% vs. 27.9%, p = 0.948], and CVM [11.8% vs. 7.3%, p = 0.441; 23.5% vs. 16.2%, p = 0.239]. Lastly, there was no difference in CVM at 1 year and 30 months [11.1% vs. 12.5%, p = 0.889; 22.2% vs. 25.0%, p = 0.742]. Conclusions Analyzing a limited group (n = 34) of ViV-TAVI procedures out of 1206 TAVIs done at a single institution, ViV-TAVI appeared to be an acceptable approach in patients not deemed appropriate candidates for redo valve replacement surgery. Clinical outcomes of ViV-TAVI were comparable to TAVI for native valve stenosis.
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Affiliation(s)
- Peter V. Bartos
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
- Károly Rácz Doctoral School of Clinical Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Balazs Molnar
- Károly Rácz Doctoral School of Clinical Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Zoltan Herold
- Division of Oncology, Department of Internal Medicine and Oncology, Semmelweis University, 1083 Budapest, Hungary
| | - Gabor Dekany
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
- Károly Rácz Doctoral School of Clinical Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Zsolt Piroth
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
| | - Gergely Horvath
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
| | - Abdelkrim Ahres
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
- Károly Rácz Doctoral School of Clinical Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Christian M Heesch
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
- Department of Interventional Cardiology, Florida Heart Clinic, Hallandale Beach, FL 33009, USA
| | - Nikoletta R. Czobor
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
| | - Sai Satish
- Department of Interventional Cardiology, Apollo Hospital, 600006 Chennai, India
| | - Tunde Pinter
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
| | - Geza Fontos
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
| | - Peter Andreka
- Department of Cardiology, Gottsegen National Cardiovascular Center, 1096 Budapest, Hungary
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Tarantini G, Dvir D, Tang G. Transcatheter aortic valve implantation in degenerated surgical aortic valves. EUROINTERVENTION 2021; 17:709-719. [PMID: 34665140 PMCID: PMC9725043 DOI: 10.4244/eij-d-21-00157] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) within failed bioprosthetic surgical aortic valves (valve-in-valve TAVI) has become an established procedure, currently approved for patients deemed at high risk for repeat aortic valve intervention. Although less invasive than surgical reoperation, challenges of valve-in-valve treatment include higher rates of malposition, prosthesis-patient mismatch and coronary obstruction. Thus, optimal patient selection and preprocedural planning is of the utmost importance to minimise the risk of these complications. In this review article we provide a fully illustrated overview of the most significant periprocedural operative considerations for valve-in-valve TAVI.
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Affiliation(s)
- Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Via Giustiniani 2, 35128 Padua, Italy
| | - Danny Dvir
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Gilbert Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, NY, USA
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Attizzani GF, Dallan LAP, Forrest JK, Reardon MJ, Szeto WY, Liu F, Pelletier M. Redo-transcatheter aortic valve replacement with the supra-annular, self-expandable Evolut platform: Insights from the Transcatheter valve Therapy Registry. Catheter Cardiovasc Interv 2021; 99:869-876. [PMID: 34533891 DOI: 10.1002/ccd.29941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/23/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To assess the safety profile of redo-TAVR procedures from patients in the transcatheter valve therapy (TVT) Registry. BACKGROUND The use of transcatheter aortic valves (TAV) to treat previously implanted failing TAVS (TAV-in-TAV) has been an increasingly important topic as indications for TAVR move to younger and lower-risk patients, but data on the safety and efficacy of redo-TAVR is limited. METHODS Patients undergoing redo-TAVR procedures using the Evolut R, Evolut PRO or Evolut PRO+ valve in the TVT Registry between April 2015 and March 2020 were included. In-hospital, 30-day and 1-year outcomes were analyzed. RESULTS Redo-TAVR was performed in 292 patients (213 patients received the Evolut R valve and 79 received the Evolut PRO or PRO+ valve). Device success was achieved in 94.5%. In-hospital mortality was 2.1%, stroke occurred in 2.7%, and 77.2% of patients were discharged home. There were no cases of coronary compression/obstruction or myocardial infarction that occurred in index hospitalization. Mean gradient at 30-days was 11.9 ± 6.9 mmHg, and 73.1% had none/trace total aortic regurgitation. CONCLUSIONS Results from the TVT Registry demonstrate good short-term outcomes after redo-TAVR with the supra-annular, self-expandable Evolut platform. Long-term follow-up is necessary to further expand understanding this complex scenario.
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Affiliation(s)
- Guilherme F Attizzani
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luis Augusto P Dallan
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - John K Forrest
- Departments of Internal Medicine and Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael J Reardon
- Department of Cardiothoracic Surgery, Methodist DeBakey Heart and Vascular Center, Houston Methodist, Houston, Texas, USA
| | - Wilson Y Szeto
- Department of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Fang Liu
- Structural Heart and Aortic Statistics Department, Medtronic, Mounds View, Minnesota, USA
| | - Marc Pelletier
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Duncan A, Quarto C, Davies S. Midterm Degeneration of Transcatheter Heart Valve Device following Valve-in-Valve Transcatheter Aortic Valve Replacement Requiring Repeat Transcatheter Aortic Valve Replacement. CASE 2020; 4:291-298. [PMID: 32875198 PMCID: PMC7451866 DOI: 10.1016/j.case.2020.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
ViV-TAVR is an alternative to redo-SAVR in patients with a degenerate surgical bioprosthesis. Optimal TAVR device positioning is crucial in determining procedural durability. TAVR-in-TAVR can be performed to treat a degenerated ViV-TAVR device. Coronary obstruction, limited coronary access, and device thrombosis may occur.
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Dvir D, Bapat V. Feasibility of TAVR in Small Surgical Valves: Vive la Valve-in-Valve. JACC Cardiovasc Interv 2019; 12:933-935. [PMID: 31122350 DOI: 10.1016/j.jcin.2019.04.003] [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: 04/07/2019] [Accepted: 04/07/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Danny Dvir
- University of Washington Medical Center, Seattle, Washington.
| | - Vinayak Bapat
- Columbia University Medical Center, New York, New York
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Commentary: Too small will fail: Reconsidering the present with an eye toward the future. J Thorac Cardiovasc Surg 2019; 158:1028-1029. [PMID: 30600080 DOI: 10.1016/j.jtcvs.2018.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/16/2018] [Indexed: 11/21/2022]
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Sachdev S, Bardia N, Nguyen L, Omar B. Bioprosthetic Valve Thrombosis. Cardiol Res 2018; 9:335-342. [PMID: 30627283 PMCID: PMC6306127 DOI: 10.14740/cr789] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/25/2018] [Indexed: 11/14/2022] Open
Abstract
Degenerative valve disease is on the rise with greater than 100,000 valve operations performed in the US alone per year. The majority of those procedures employ tissue bioprostheses to avoid the attendant risk of anticoagulation, especially in the elderly. Though traditionally this approach has been considered a superior option to avoid anticoagulation, more recent analyses have demonstrated a significant incidence of previously unrecognized thrombosis associated with bioprosthetic valves, especially with the more recent advent of the transcatheter aortic valve replacement implantations. Bioprosthetic valve thrombosis is a major cause of either acute or indolent bioprosthetic valve degeneration, and often has an elusive presentation causing delayed recognition and treatment. The literature has extensively addressed the risks and benefits of anticoagulation following bioprosthetic valve replacement to prevent bioprosthetic valve thrombosis (BPVT), without conclusive evidence-based recommendations. The duration of anticoagulation following an episode of BPVT is unclear, and lifelong anticoagulation has been suggested. The increasing use of transcatheter aortic valve replacement as an alternative to surgical aortic valve replacement in various risk groups has introduced new challenges with regards to valve thrombosis, which have been poorly studied with regards to optimal treatment and prevention. The increasing use of valve-in-valve procedures is expected to bring on further uncharted challenges.
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Affiliation(s)
| | - Nikky Bardia
- University of South Alabama, Mobile, AL 36617, USA
| | | | - Bassam Omar
- University of South Alabama, Mobile, AL 36617, USA
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