Lifetime Management of Patients With Severe Aortic Stenosis in the Era of Transcatheter Aortic Valve Replacement

Long-term clinical outcomes in patients between the age of 50-70 years receiving biological versus mechanical aortic valve prostheses

OBJECTIVES

The last 2 decades have seen an incremental use of biological over mechanical prostheses. However, while short-term clinical outcomes are largely equivalent, there is still controversy about long-term outcomes.

METHODS

All patients between the ages of 50 and 70 years undergoing elective/urgent isolated aortic valve replacement at our institute between 1996 and 2023 were included. Trends, early, and long-term outcomes were investigated.

RESULTS

A total of 1708 (61% male) patients with a median age of 63.60 (interquartile range: 58.28-67.0) years were included of which 1191 (69.7%) received a biological prosthesis. After inverse propensity score weighting, there were no short-term differences when comparing patients receiving biological and mechanical valves. However, patients who received mechanical prostheses had better long-term survival (P < 0.001). Sub-group analysis revealed that patients with biological size 19 mm prosthesis had the worst long-term survival. Patients with a size 21-mm mechanical prosthesis had better survival compared to both size 19-mm [hazard ratio (HR) 0.25, 95% confidence interval (CI) 0.17-0.37, P < 0.001], 21-mm (HR 0.33, 95% CI 0.23-0.48, P < 0.001) and 23-mm (HR 0.40, 95% CI 0.27-0.60, P < 0.001) biological prosthesis. Additionally, patients with severe patient-prosthesis mismatch exhibited the lowest survival rate compared to those with moderate or no (HR 1.56, 95% CI 1.21-2.00, P < 0.001).

CONCLUSIONS

Patients aged between 50 and 70 years with a mechanical aortic prosthesis had better long-term survival compared to those with a biological prosthesis. Our study underscores the need for a critical re-evaluation of prosthesis selection strategies in this age group.

Increased Risk of Surgical Aortic Valve Replacement After Prior Transcatheter vs Surgical Aortic Valve Replacement With Concomitant Valve Disease

BACKGROUND

The cause of increased risk for reoperation after transcatheter aortic valve replacement (TAVR) vs prior surgical aortic valve replacement (SAVR) is poorly understood. This study evaluated the impact of concomitant mitral and tricuspid valve disease on associated risk of TAVR explantation.

METHODS

Patients undergoing aortic valve replacement after prior SAVR or TAVR were extracted from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2021). Patients were stratified by TAVR explantation status and presence of severe concomitant valve disease for analyses. Risk adjustment was performed by multivariable logistic regression. Interaction terms were used to evaluate differential risk of concomitant valve disease for TAVR explantation vs redo-SAVR.

RESULTS

Of 24,097 redo aortic valve replacement patients, 877 (3.6%) underwent TAVR explantation. TAVR explantation patients had higher rates of concomitant severe valve disease (17% vs 14%; P < .001). Patients with severe concomitant valve disease had worse operative mortality after TAVR explantation (26.2% vs 14.6%; P < .001) and redo-SAVR (12.3% vs 6.9%; p < .001). TAVR explantation was independently associated with higher mortality (adjusted odds ratio [ORadj], 1.3 [1.0-1.6]; P = .030). Severe mitral regurgitation (ORadj, 1.2 [1.0-1.6]; P = .017), mitral stenosis (ORadj, 2.0 [1.5-2.7; P < .001), and tricuspid regurgitation (ORadj, 1.6 [1.3-1.9]; P < .001) were all associated with mortality, although these factors were not associated with disproportionately higher risk during TAVR explantation (P > .05).

CONCLUSIONS

TAVR explantation cases have a higher burden of severe concomitant valve disease than redo-SAVR cases. Heart teams should consider these findings when discussing initial procedure choices for patients with multivalve disease, given their extreme risk at time of TAVR explantation.

Redo-TAVI with the SAPIEN 3 valve in degenerated calcified CoreValve/Evolut explants

BACKGROUND

Redo-transcatheter aortic valve implantation (TAVI) is the treatment of choice for failed transcatheter aortic valves. Currently, implantation of a SAPIEN 3 (S3) is indicated for redo-TAVI in degenerated CoreValve/Evolut (CV/EV) transcatheter aortic valves (TAVs) but is not well understood.

AIMS

We aimed to evaluate S3 function following implantation in explanted calcified CV/EV TAVs and to assess the impact of CV/EV pathology on redo-TAVI outcomes.

METHODS

Ex vivo hydrodynamic testing was performed per the International Organization for Standardization (ISO) 5840-3 standard on 4 S3 TAVs implanted at node 5 in calcified CV/EV explants. The mean gradient (MG), effective orifice area (EOA), peak velocity, regurgitant fraction (RF), geometric orifice area (GOA), leaflet overhang, leaflet pinwheeling, neoskirt height, and frame deformation were evaluated.

RESULTS

CV/EV explants were calcified and stenotic. Following S3 implantation, the MG and peak velocity decreased. As per the ISO standard, all S3 implants showed adequate EOA, and 3 out of 4 had an RF within the accepted value (<20%). CV/EV leaflet overhang ranged from 25-37%. Calcified leaflets remained stationary throughout the cardiac cycle (difference <9%) and were not pinned in a manner that constrained S3 systolic flow or appeared to prevent selective frame cannulation. The downstream CV/EV GOA was larger than the upstream S3 GOA during systole. S3 frame underexpansion was seen, resulting in leaflet pinwheeling (range 13-30%). Above the neoskirt, calcium protrusion was observed in contact with the S3 leaflets.

CONCLUSIONS

S3 implantation at node 5 in calcified CV/EV valves resulted in satisfactory hydrodynamic performance in most configurations tested with stable leaflet overhang throughout the cardiac cycle. The long-term implications of S3 underexpansion, leaflet pinwheeling, and calcium protrusion require future studies.