Treatment of late paravalvular regurgitation after transcatheter aortic valve implantation: prognostic implications

BACKGROUND AND AIMS

Paravalvular regurgitation (PVR) after transcatheter aortic valve implantation (TAVI) is associated with increased morbidity and mortality. The effect of transcatheter interventions to treat PVR after the index TAVI was investigated.

METHODS

A registry of consecutive patients who underwent transcatheter intervention for ≥ moderate PVR after the index TAVI at 22 centers. Principal outcomes were residual aortic regurgitation (AR) and mortality at 1 year after PVR treatment.

RESULTS

A total of 201 patients were identified: 87 (43%) underwent redo-TAVI, 79 (39%) plug closure and 35 (18%) balloon valvuloplasty. Median TAVI-to-re-intervention time was 207 (35; 765) days. The failed valve was self-expanding in 129 (63.9%) patients. Most frequent devices utilized were a Sapien 3 valve for redo-TAVI (55, 64%), an AVP II as plug (33, 42%) and a True balloon for valvuloplasty (20, 56%). At 30 days, AR ≥ moderate persisted in 33 (17.4%) patients: 8 (9.9%) after redo-TAVI, 18 (25.9%) after plug and 7 (21.9%) after valvuloplasty (p=0.036). Overall mortality was 10 (5.0%) at 30 days and 29 (14.4%) at 1 year: 0, 8 (10.1%) and 2 (5.7%) at 30 days (p=0.010); and 11 (12.6%), 14 (17.7%) and 4 (11.4%) at 1 year (p=0.418), after redo-TAVI, plug and valvuloplasty, respectively. Regardless of treatment strategy, patients in whom AR was reduced to ≤ mild had lower mortality at 1 year compared to those with AR persisting ≥ moderate [11 (8.0%) vs. 6 (21.4%); p=0.007].

CONCLUSIONS

This study describes the efficacy of transcatheter treatments for PVR after TAVI. Patients in whom PVR was successfully reduced had better prognosis. The selection of patients and optimal PVR treatment modality require further investigation.

Transcatheter aortic valve-in-valve implantation to treat aortic Para-valvular regurgitation after TAVI

BACKGROUND

Para-valvular regurgitation (PVR) after transcatheter aortic valve (TAV) implantation is associated with increased mortality. Redo-TAVI may be applied to treat PVR, yet with unknown efficacy. We thought to assess redo-TAVI efficacy in reducing PVR using the Redo-TAVI registry (45 centers; 600 TAV-in-TAV cases).

METHODS

Patients were excluded if redo-TAVI was done urgently (N = 253), for isolated TAV stenosis (N = 107) or if regurgitation location at presentation remained undetermined (N = 123). The study group of patients with PVR (N = 70) were compared against patients with intra-valvular regurgitation (IVR) (N = 41). Echocardiographic examinations of 67 (60%) patients were reassessed in a core-lab for data accuracy validation.

RESULTS

Core-lab examination validated the jet location in 66 (98.5%) patients. At 30 days, the rate of residual AR ≥ moderate was 7 (10%) in the PVR cohort vs. 1 (2.4%) in the IVR cohort, p = 0.137. The rate of procedural success was 53 (75.7%) vs. 33 (80.5%), p = 0.561; procedural safety 51 (72.8%) vs. 31 (75.6%), p = 0.727; and mortality 2 (2.9%) vs. 1 (2.4%), p = 0.896 at 30 days and 7 (18.6%) vs. 2 (11.5%), p = 0.671 at 1 year, respectively. Of patients with residual PVR ≥ moderate at 30 days, 5/7 occurred after implanting balloon-expandable in self-expanding TAV and 2/7 after balloon-expandable in balloon-expandable TAV.

CONCLUSIONS

This study puts in perspective redo-TAVI efficacy and limitations to treat PVR after TAVI. Patient selection for this and other therapies for PVR needs further investigation.

[Cardiomyopathy in hypocalcemia]

A 48-year-old woman developed a hypocalcaemic cardiomyopathy, the hypocalcaemia being due to hypoparathyroidism after three previous thyroid operations for goitre with tracheal compression. She had signs of severe cardiac failure, but no tetany. She was put on calcium and vitamin D3 medication which raised calcium concentration. The cardiac status improved, as did the radiological and echocardiographic findings, without the patient having received any diuretics, digitalis or afterload lowering drugs.