Transcatheter aortic valve implantation: current trends and future directions

Health-related quality of life following TAVI or cardiac surgery in patients at intermediate and low risk: a systematic review and meta-analysis

Recent randomised trials have shown that clinical outcomes with transcatheter aortic valve implantation (TAVI) are non-inferior to surgical aortic valve replacement (SAVR) in patients with symptomatic aortic stenosis at intermediate to low risk. Health-related quality of life (HrQoL) outcomes in these patient groups remain uncertain. A systematic search of the literature was conducted that included nine trials and 11,295 patients. Kansas City Cardiomyopathy Questionnaire (KCCQ), a heart-failure-specific measure and EuroQol-5D (EQ-5D) (a generic health status tool) changes were the primary outcomes. New York Heart Association (NYHA) classification was the secondary outcome. Improvement in KCCQ scores was greater with TAVI (mean difference (MD)=13.56, 95% confidence interval (CI) 11.67-15.46, p<0.001) at 1 month, as was the improvement in EQ-5D (MD=0.07, 95% CI 0.05-0.08, p<0.001). There was no difference in KCCQ (MD=1.05, 95% CI -0.11 to 2.21, p=0.08) or EQ-5D (MD=-0.01, 95% CI -0.03 to 0.01), p=0.37) at 12 months. NYHA functional class 3/4 was lower in patients undergoing TAVI at 1 month (MD=0.51, 95% CI 0.34-0.78, p=0.002), but there was no difference at 12 months (MD=1.10; 95% CI 0.87-1.38, p=0.43). Overall, TAVI offers early benefit in HRQoL outcomes compared with SAVR, but they are equivalent at 12 months.

2006 to 2019 Story; percutaneously implantable aortic valve prototypes

Aims

A review was conducted on the composition, advantages and limitations of available aortic valve prototypes to create an ideal valve for percutaneous implantation.

Patients

Patients with multiple comorbidities who cannot withstand the risks of open cardiac surgery.

Methodology

The search was performed using online databases and textbooks. Articles were excluded based on specific criterion.

Results

Ten prototypes created between 2006 and 2019 were found and reviewed. The prototypes had a set of advantages and limitations with their characteristics coinciding at times.

Conclusions

The ideal percutaneously implantable aortic valve should have minimum coaptation height, zero folds in the leaflets, minimum valve height, minimum leaflet flexion and three leaflets. It can be composed of biological or synthetic material, as long as it provides minimal risk of thrombosis. However, more studies are needed to ensure other ideal parameters.

Comparison of Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients ≥80 Years of Age

Transcatheter aortic valve implantation (TAVI) procedures have increased exponentially since FDA approval in 2011. Older patients who underwent aortic valve replacement, either TAVI or surgical aortic valve replacement (SAVR), have elevated risk. Using the National Readmission Database, we included patients ≥80 years who underwent either TAVI or SAVR from 2011 to 2015. In-hospital outcomes of TAVI versus SAVR were compared using propensity-matched analysis to reduce the confounding effect of between-group imbalances. We identified a total of 30,590 TAVI and 54,204 SAVR procedures performed during the study period. The propensity score-matching algorithm yielded 19,713 patients in each group. The in-hospital mortality rates were significantly lower in TAVI compared with SAVR (3.4% vs 6.8%, p <0.001). Similarly, the 30-day readmission rate (15.2% vs 18.1% p = 0.001), in-hospital complications, mean length of stay (7 vs 12 days, p <0.001), and hospital cost (US$ 60,534 vs US$ 67,426) were significantly lower for TAVI patients. There was a significant increase in the use of TAVI (26 cased per month in 2011 to 1,237/month in 2015) and a decrease in SAVR (1,409/month in 2011 to 859/month in 2015) during the study period. In-patient mortality significantly decreased for patients who underwent TAVI (4.4% in 2011 to 2.5% in 2015) and did not significantly change for patients who underwent SAVR (5.0% in 2011 to 4.7% in 2015). Overall, the number of SAVR procedures remained two thirds higher than TAVI. In conclusion, in octo- and nonagenarians, TAVI is an effective and safer alternative to SAVR as it is associated with lower in-hospital mortality, lower major in-hospital complications, lower 30-day readmission rate, and hospital costs. Despite this, SAVR remained the most common approach in octogenarians, although the trends in this data set, suggest a shift in practice patterns for this cohort.

Endovascular Versus Transapical Transcatheter Aortic Valve Replacement: In-hospital Mortality, Hospital Outcomes, and 30-day Readmission. A Propensity Score-matched Analysis

INTRODUCTION

Transapical transcatheter aortic valve replacement (TAVR) is associated with increased morbidity compared with endovascular TAVR. We sought to compare the differences in clinical outcomes between endovascular and transapical TAVR approaches utilizing a propensity score model.

METHODS

Patients undergoing TAVR (International Classification of Diseases, Ninth Revision, Clinical Modification codes 35.05 and 35.06) between January 2011 and November 2014 were identified in the Nationwide Readmissions Database, and a propensity score-matched analysis was performed comparing transapical versus endovascular approach. The primary outcome of interest was in-hospital mortality and 30-day all-cause readmission. We also evaluated trends in use of TAVR over the years.

RESULTS

We identified 28,302 endovascular TAVR and 7967 transapical TAVR performed during the study period. The propensity score-matching algorithm yielded 7879 well-matched patients in each group. The in-hospital mortality rates were significantly lower in endovascular TAVR compared with transapical TAVR (1.7% vs 6.7%; OR, 0.24; 95% CI, 0.17- 0.35; P < 0.001). The 30-day readmission rate was lower in endovascular TAVR (14.4% vs 16.8%; OR, 0.83; 95% CI, 0.70-0.98; P = 0.036). Use of TAVR increased from 585 (74% endovascular TAVR) in 2011 to 16,801 in 2014 (82.8% endovascular TAVR).

CONCLUSIONS

Endovascular TAVR is associated with significantly lower in-patient mortality and lower readmission rate when compared with transapical TAVR. Heart failure remains the most common cause for readmission after TAVR regardless of approach.

Comparison of latest generation transfemoral self-expandable and balloon-expandable transcatheter heart valves

OBJECTIVES

We herein aimed to compare acute 30-day outcomes of latest-generation self-expandable and balloon-expandable transcatheter heart valves.

METHODS

From 2012 through 2016, 104 consecutive patients (study group, 69.2% female, 81.7 ± 5.5 years, logEuroSCORE I 15.9 ± 9.3%) received transfemoral transcatheter aortic valve implantation using the Symetis ACURATE neo® transcatheter heart valve. A control group of patients after transfemoral transcatheter aortic valve implantation with the Edwards Sapien 3™ transcatheter heart valve was retrieved from our database and matched to the study group. Data were retrospectively analysed according to updated Valve Academic Research Consortium definitions.

RESULTS

Device success was 94.2% (98 of 104) and 98.1% (102 of 104) in study and control groups, respectively (P = 0.157). All-cause 30-day mortality was 3.9 (4 of 104) vs 0.9% (1 of 104) (P = 0.317). Resultant transvalvular peak/mean gradients and effective orifice area were 14.2 ± 5.7 vs 22.6 ± 6.8 mmHg (P < 0.001)/7.3 ± 2.8 vs 11.8 ± 3.5 mmHg (P < 0.001) and 2.0 ± 0.4 vs 1.7 ± 0.4 cm2 (P = 0.063). Paravalvular leakage ≥moderate was observed in 4.8% (5 of 104) and 1.9% (2 of 104) (P = 0.257). Rate of permanent pacemaker implantation was 10.6% (11 of 104) vs 16.4% (17 of 104) (P = 0.239).

CONCLUSIONS

Next-generation self-expandable transcatheter heart valves preserve superiority in terms of post-interventional haemodynamics without presenting former drawbacks: rate of postoperative permanent pacemaker implantation and severity of residual paravalvular leakage were similar to balloon-expandable transcatheter heart valves.

Failed TAVI in TAVI Implantation: TAVI Dislocation Followed by Ensuing Surgical Graft Resection

We are presenting a case report of failed valve-in-valve treatment of severe aortic stenosis. A control ultrasonography after TAVI implantation revealed a severe aortic regurgitation of the graft which was subsequently unresolved with postimplantation dilatation. Second TAVI was implanted with cranial dislocation to the aortic root. Patient underwent a CT examination to clarify the TAVI in TAVI position. Patient underwent a surgical resection of TAVI with implantation of biological aortic valve prosthesis. In situations where TAVI treatment fails or is complicated beyond the possibility of endovascular repair, surgical intervention despite its higher risks is the preferred choice.