Transcatheter aortic valve implantation in patients with extra-small aortic annuli

Self-Expandable Versus Balloon-Expandable Transcatheter Aortic Valve Replacement for Treatment of Patients With Small Aortic Annulus: An Updated Meta-Analysis of Reconstructed Individual Patient Data

Transcatheter aortic valve replacement has emerged as an effective alternative to surgery in selected patients with aortic stenosis. It needs to be made clear which type of valve has better results in patients with small aortic annulus. We searched PubMed, Scopus, Embase, Cochrane Library, and Web of Science, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A total of 27 articles were included, including 10,378 patients [5989 in balloon-expanding valve (BEV) and 4389 in the self-expanding valve (SEV) groups] with small aortic annulus. Our meta-analysis demonstrated no significant difference between SEVs and BEVs for 1-year all-cause mortality. There was a statistically significant increased risk of permanent pacemaker implantation (PPI) within 30 days and ischemic stroke at 1 year with SEVs [risk ratio (RR) = 1.69, 95% confidence interval (CI) = 1.18-2.42, P < 0.01, and RR = 1.83, 95% CI = 1.03-3.26, P = 0.04, respectively]. Our meta-analysis showed that SEVs are favored over BEVs in terms of 1-year change from baseline in effective orifice area (mean difference = 0.45, 95% CI = 0.19-0.71, P < 0.01). Moreover, after 1-year follow-up, severe patient-prosthesis mismatch was significantly lower in the SEV group (RR = 0.24, 95% CI = 0.11-0.53, P < 0.01). In conclusion, SEVs were associated with better echocardiographic outcomes from baseline. Patients with SEVs were more likely to develop stroke and require PPI but were less likely to have patient-prosthesis mismatch. The benefit of a larger effective aortic valve area with SEVs has to be balanced against higher PPI and stroke rates.

Navitor™ in Evolut™: a case report illustrating a novel approach to redo-transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) is expanding to younger patients, and the management of valve failure is a growing clinical problem. The transcatheter heart valve (THV) of choice for redo-TAVI is a complex decision, and first reports have examined the use of the Sapien 3™ THV (Edwards Lifesciences; Irvine, CA, USA) in failed Evolut™ (Medtronic, Minneapolis, MN, USA) THV. However, several different technical approaches may be worth consideration, and the subject remains a matter of debate.

Case summary

A 73-year-old female with previous coronary artery bypass grafting, percutaneous coronary intervention (PCI), and TAVI with a 26 mm Evolut™ R THV presented with signs of heart failure. The clinical investigation revealed a severe restenosis of the THV valve and a stenosis of the left coronary main stem. The patient was successfully treated with PCI of the left main and, during the same procedure, underwent implantation of a 25 mm Navitor™ THV (Abbott; Chicago, IL, USA).

Discussion

This case presentation aims to illustrate the rationale of and necessary conditions for performing a TAVI-in-TAVI procedure with Navitor™ THV in a failed Evolut™ THV which, to our best knowledge, constitutes a novel approach to redo-TAVI.

Impact of Small Aortic Annuli on the Performance of Transcatheter Aortic Valve Replacement Bioprostheses: An Updated Meta-Analysis of Recent Studies

A metanalysis of available randomized controlled trials and observational studies comparing self-expanding (SE) and balloon-expandable (BE) bioprostheses in patients with small aortic annulus and aortic stenosis for short- and midterm hemodynamic and clinical outcomes was performed. A total of 21 studies with a total 8,647 patients (SE: n = 4,336 patients vs BE: n = 4,311 patients) were included. SE bioprostheses had a lower postoperative mean gradient at 30 days (Mean Difference [MD] -5.16, 95% confidence interval [CI] 4.7 to 5.5, p <0.001) and at 1 year (MD -6.6, 95%CI 6.1 to 7.03, p <0.001), with a larger indexed effective orifice area (0.17, 95% CI 0.13 to 0.22, p <0.001 and 0.17, 95% CI 0.08 to 0.27, p <0.001) at both time intervals. BE bioprostheses had a higher risk of 30-day and 1-year severe prosthesis-patient mismatch (risk ratio [RR] 1.07, 95% CI 1.04 to 1.09, p <0.001; RR 1.07, 95% CI 1.04 to 1.11, p <0.001). The 30-day and 1 year paravalvular leaks (RR 0.99, 95% CI 0.98 to 0.99, p <0.001; RR 0.89, 95% CI 0.82 to 0.95, p <0.001) and permanent pacemaker implantation (RR 0.97, 95% CI 0.94 to 0.99, p 0.01, I2 = 40%,) were lower in the BE group. BE bioprostheses were associated with a lower risk of in-hospital stroke (RR 0.99, 95% CI 0.98 to 1, p = 0.01). In conclusion, in patients with small aortic annulus and aortic stenosis, SE bioprostheses have superior hemodynamic performance but higher rates of paravalvular leak, permanent pacemaker implantation, and in-hospital stroke. BE bioprostheses were associated with a higher risk of severe prosthesis-patient mismatch.

Transcatheter or Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis and Small Aortic Annulus: A Randomized Clinical Trial

BACKGROUND

The optimal treatment in patients with severe aortic stenosis and small aortic annulus (SAA) remains to be determined. This study aimed to compare the hemodynamic and clinical outcomes between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with a SAA.

METHODS

This prospective multicenter international randomized trial was performed in 15 university hospitals. Participants were 151 patients with severe aortic stenosis and SAA (mean diameter <23 mm) randomized (1:1) to TAVR (n=77) versus SAVR (n=74). The primary outcome was impaired valve hemodynamics (ie, severe prosthesis patient mismatch or moderate-severe aortic regurgitation) at 60 days as evaluated by Doppler echocardiography and analyzed in a central echocardiography core laboratory. Clinical events were secondary outcomes.

RESULTS

The mean age of the participants was 75.5±5.1 years, with 140 (93%) women, a median Society of Thoracic Surgeons predicted risk of mortality of 2.50% (interquartile range, 1.67%-3.28%), and a median annulus diameter of 21.1 mm (interquartile range, 20.4-22.0 mm). There were no differences between groups in the rate of severe prosthesis patient mismatch (TAVR, 4 [5.6%]; SAVR, 7 [10.3%]; P=0.30) and moderate-severe aortic regurgitation (none in both groups). No differences were found between groups in mortality rate (TAVR, 1 [1.3%]; SAVR, 1 [1.4%]; P=1.00) and stroke (TAVR, 0; SAVR, 2 [2.7%]; P=0.24) at 30 days. After a median follow-up of 2 (interquartile range, 1-4) years, there were no differences between groups in mortality rate (TAVR, 7 [9.1%]; SAVR, 6 [8.1%]; P=0.89), stroke (TAVR, 3 [3.9%]; SAVR, 3 [4.1%]; P=0.95), and cardiac hospitalization (TAVR, 15 [19.5%]; SAVR, 15 [20.3%]; P=0.80).

CONCLUSIONS

In patients with severe aortic stenosis and SAA (women in the majority), there was no evidence of superiority of contemporary TAVR versus SAVR in valve hemodynamic results. After a median follow-up of 2 years, there were no differences in clinical outcomes between groups. These findings suggest that the 2 therapies represent a valid alternative for treating patients with severe aortic stenosis and SAA, and treatment selection should likely be individualized according to baseline characteristics, additional anatomical risk factors, and patient preference. However, the results of this study should be interpreted with caution because of the limited sample size leading to an underpowered study, and need to be confirmed in future larger studies.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03383445.

Managing the challenge of a small aortic annulus in patients with severe aortic stenosis

INTRODUCTION

Small aortic annulus (SAA) poses a challenge in the management of patients with severe aortic stenosis requiring aortic valve replacement - both surgical and transcatheter - since it has been associated with worse clinical outcomes.

AREAS COVERED

This review aims to comprehensively summarize the available evidence regarding the management of aortic stenosis in patients with SAA and discuss the current controversies as well as future perspectives in this field.

EXPERT OPINION

It is paramount to agree in a common definition for diagnosing and properly treating SAA patients, and for that purpose, multidetector computer tomography is essential. The results of recent trials led to the expansion of transcatheter aortic valve replacement among patients of all the surgical-risk spectrum, and the choice of treatment (transcatheter, surgical) should be based on patient comorbidities, anatomical characteristics, and patient preferences.