Evaluation and Management of Paravalvular Aortic Regurgitation After Transcatheter Aortic Valve Replacement

Aortic balloon valvuloplasty outcome according to calcium distribution and valve geometry - The ABCD study

BACKGROUND

There is little data on the outcome of balloon aortic valvuloplasty (BAV) in relation to valve dimensions and calcification patterns. The procedure is not standardized, particularly the choice of balloon size.

METHODS

This retrospective multicenter study focused on BAV efficacy and safety by analyzing the relationship between balloon size, annulus geometry (i.e., diameters, perimeter, and area), and calcification patterns (total burden and calcium distribution over each individual leaflet). From March 2018 to March 2023, all consecutive patients who underwent clinically indicated BAV and ECG-gated multidetector computed tomography of the aorta were included, except those with a bicuspid valve. Calcium score was calculated on contrast-enhanced images based on a luminal attenuation threshold of +100 HU.

RESULTS

One hundred and fifteen patients were included. Procedural success was 82.6 %. The balloon-to-annulus ratio (BAR) relative to diameter, perimeter, and area was higher in patients with successful BAV. Patients with unsuccessful BAV had a significantly higher aortic valve calcium burden. The complication rate was 4.3 % and there was no association with valve geometry or calcium burden. A trend towards a reduced complication rate was found as calcium asymmetry increased. BAR minimum annulus diameter was the best parameter in predicting procedural success, with a cut-off at 0.85.

CONCLUSIONS

BAV efficacy is correlated directly with balloon size in relation to annulus dimension and inversely with total calcium burden. The minimum diameter of the valve may be adopted as a reference for balloon sizing.

Transcatheter versus surgical aortic valve replacement in patients with aortic stenosis with a small aortic annulus: A meta-analysis with reconstructed time to event data

Background

Aortic stenosis (AS) remains a prevalent and serious global health concern, exacerbated by an aging population worldwide. This valvular disease, when symptomatic and without appropriate intervention, severe AS can drastically reduce life expectancy. In our systematic review and meta-analysis, we aim to synthesize available evidence to guide clinical decision-making by comparing the performance of TAVR and SAVR, specifically in patients with severe AS and a small aortic annulus.

Methods

We searched PubMed, EMBASE, Cochrane, Web of Science, and Scopus from inception till May 2024. The risk ratio (RR) and mean difference (MD) with a 95 % confidence interval (CI) are provided as effect size estimates, with all analyses being conducted using RevMan 5.4.

Results

Eleven studies with 3,670 patients were included. TAVR significantly increased the risk of 2-year new permanent pacemaker implantation (PPI) (RR = 2.42; 95 % CI: [1.70-3.44], P < 0.0001) and major vascular complications (RR = 3.73; 95 % CI: [1.98-6.99], P < 0.0001) than SAVR. However, TAVR significantly decreased the risk of patient-prosthesis mismatch (PPM) (RR = 0.56; 95 % CI: [0.48-0.65], P < 0.00001) and new-onset atrial fibrillation (AF) (RR = 0.31; 95 % CI: [0.23-0.41], P < 0.00001). Also, SAVR reduced the risk of paravalvular leak (PVL) (RR = 3.35; 95 % CI: [1.79-6.27], P = 0.0002).

Conclusion

TAVR had a significantly reduced risk of PPM and new-onset AF but with increased PPI and vascular complications. Also, TAVR significantly improved EOA and iEOA. Furthermore, SAVR had less risk of PVL, and better LVEF improvement at predischarge. Therefore, TAVR and SAVR remain valid alternatives, and decisions should be based on anatomy of the annulus and aortic root,operative risk, and comorbidities.

Long-Term Clinical Impact of Paravalvular Leak Following Transcatheter Aortic Valve Implantation

Background: Paravalvular leak (PVL) was initially recognized as one of the most common complications after transcatheter aortic valve implantation (TAVI) and has been linked to adverse clinical outcomes, including mortality. This study aims to assess the long-term clinical effects of PVL in patients undergoing TAVI with the latest generation of transcatheter aortic valves, as part of the national observational prospective multicenter study OBSERVANT II. Methods: OBSERVANT II included all consecutive patients with severe aortic stenosis who underwent TAVI across 28 Italian centers from December 2016 to September 2018. A total of 2125 patients were included in this analysis and stratified according to the presence of moderate-to-severe PVL (significant PVL, n = 155) versus no/trace-to-mild PVL (no significant PVL, n = 1970). The primary endpoint was 5-year major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, stroke, myocardial infarction, and coronary revascularization. Five-year all cause death and re-hospitalization for heart failure (HF) were the secondary endpoints. Results: In our cohort, the incidence of moderate-to-severe PVL was 7%. Age, aortic anulus perimeter, and self-expandable valves were determinants of PVL. The risk of MACCE, all-cause death, and re-hospitalization for HF at the 5-year follow-up were not different between the study groups [HR = 1.07 (95% CI: 0.85-1.34) p = 0.571; HR = 1.10 (95% CI: 0.87-1.39) p = 0.435; HR = 1.20 (95% CI: 0.88-1.62) p = 0.245, respectively]. Conclusions: In this analysis of the OBSERVANT II study, moderate/severe PVL was not associated with a higher incidence of MACCE and re-hospitalization for heart failure at the 5-year follow-up.

Parameterization, algorithmic modeling, and fluid-structure interaction analysis for generative design of transcatheter aortic valves

Heart valves play a critical role in maintaining proper cardiovascular function in the human heart; however, valve diseases can lead to improper valvular function and reduced cardiovascular performance. Depending on the extent and severity of the valvular disease, replacement operations are often required to ensure that the heart continues to operate properly in the cardiac system. Transcatheter aortic valve replacement (TAVR) procedures have recently emerged as a promising alternative to surgical replacement approaches because the percutaneous methods used in these implant operations are significantly less invasive than open heart surgery. Despite the advantages of transcatheter devices, the precise deployment, proper valve sizing, and stable anchoring required to securely place these valves in the aorta remain challenging even in successful TAVR procedures. This work proposes a parametric modeling approach for transcatheter heart valves (THVs) that enables flexible valvular development and sizing to effectively generate existing and novel valve designs. This study showcases two THV configurations that are analyzed using an immersogeometric fluid-structure interaction (IMGA FSI) framework to demonstrate the influence of geometric changes on THV performance. The proposed modeling framework illustrates the impact of these features on THV behavior and indicates the effectiveness of parametric modeling approaches for enhancing THV performance and efficacy in the future.

Successful Rescue Transaortic Valve Replacement Using Edwards Sapien 3 Following Failed Evolut R Implantation in a Degenerated Surgical Bioprosthesis: A Case Report

This study examines a complex scenario of structural valve degeneration (SVD) in a high surgical-risk patient with a previously implanted 25 mm Carpentier-Edwards (CE) Perimount Magna Ease 3300 (Irvine, CA: Edwards Lifesciences) surgical bioprosthetic valve (SAV), the patient presented with both paravalvular leak (PVL) and central prosthetic valve insufficiency (PVI). The patient was considered for a transaortic valve-in-valve (ViV) intervention with a self-expanding 29 mm Evolut R valve (Minneapolis, MN: Medtronic). The case describes a ViV intervention complicated by the malpositioning of the Evolut R valve secondary to micro-dislodgement into the left ventricular outflow tract (LVOT) after deployment and subsequent migration into the LVOT during an attempted bioprosthetic valve fracture (BVF) of the SAV that aimed to decrease transvalvular gradients. The resulting acute severe PVL resulted in significant hemodynamic deterioration, necessitating emergent intervention by implanting a balloon-expandable 26 mm Edwards SAPIEN 3 valve (Irvine, CA: Edwards Lifesciences), effectively averting the need for a surgical valve explant. This study illuminates the intricacies and emergency management strategies in transcatheter aortic valve replacement (TAVR) procedures, particularly in high-risk patients with SVD, and offers critical insights into the challenges and solutions in ViV implantations.

Association between three-year mortality after transcatheter aortic valve implantation and paravalvular regurgitation graded by videodensitometry in comparison with visual grading

BACKGROUND

Estimation of regurgitant fraction by videodensitometry (VD-AR) of aortic root angiograms is a new tool for objective grading of paravalvular regurgitation (PVR) after transcatheter aortic valve implantation (TAVI). Stratification with boundaries at 6% and 17% has been proposed to reflect "none/trace", "mild" and "moderate or higher" PVR.

OBJECTIVE

We sought to investigate the association of strata of VD-AR with 3-year mortality and to compare VD-AR with visual grading of angiograms.

METHODS

We interrogated our database for patients undergoing transfemoral TAVI from 2008 to 2018. Vital status of the patients was obtained from population registers. To test differences in survival and estimate adjusted hazard ratios (HRs) we fitted Cox models.

RESULTS

Our retrospective study included 699 patients with evaluable angiograms at completion of the TAVI procedure. Cumulative 3-year mortality was 35.0% in 261 (37.3%) patients with VD-AR < 6%, 33.9% in 325 (46.5%) patients with VD-AR between 6 and 17% (HR [95% confidence interval] 1.06 [0.80-1.42]; P = 0.684) and 47.2% in 113 (16.2%) patients with VD-AR > 17% (HR 1.57 [1.11-2.22]; P = 0.011). Visually, PVR was graded as "none/trace" in 470 (67.2%) patients, as "mild" in 219 (31.3%) and as "moderate" in 10 (1.4%). Both mild PVR and moderate PVR on visual grading were significantly associated with mortality (HRs 1.31 [1.12-1.54]; P = 0.001 and 1.92 [1.13-3.24]; P = 0.015; respectively).

CONCLUSIONS

VD-AR > 17%, but not VD-AR 6-17%, was independently associated with mortality. Compared with subjective visual evaluation, VD-AR resulted in a smaller proportion of patients with PVR classified as prognostically relevant.

Consistency of transesophageal echocardiography and angiography in grading paravalvular regurgitation during transcatheter aortic valve replacement

BACKGROUND

The Valve Academic Research Consortium 3 (VARC-3) standardizes the classification criteria and Doppler parameters for paravalvular regurgitation (PVR) by echocardiography. However, the consistency between transesophageal echocardiography (TEE) and angiography in grading (using the VARC-3 criteria) of PVR during transcatheter aortic valve replacement (TAVR) is unclear.

METHODS

Forty-six patients who underwent TEE and angiography during TAVR were retrospectively included. All patients had complete baseline information, TEE and angiography data. The Doppler parameters measured by TEE included the circumferential extent of PVR, regurgitation volume, regurgitation fraction, and the effective regurgitant orifice area. PVR was classified into four grades: absent, mild, moderate and severe. The weighted kappa coefficient was used to analyze the consistency between the two techniques. Kendall's W coefficient was used to evaluate the consistency of parameters measured by TEE.

RESULTS

Among all patients, there were 43 cases (93.5%) with consistent assessments between TEE and angiography. PVR was observed in 19 cases. TEE assessed mild PVR in 17 cases and moderate PVR in two cases; Angiography assessed mild PVR in 14 cases and moderate PVR in two cases. The weighted kappa coefficient between angiography and the circumferential extent of PVR, regurgitation volume, regurgitation fraction, and the effective regurgitant orifice area respectively was .84, .79, .74, .85 (P < .001). Kendall's W coefficient was .83 (P < .001).

CONCLUSIONS

TEE and angiography had strong consistency in the grading (using the VARC-3 criteria) of PVR during TAVR. TEE was a convenient diagnostic tool to quantify and grade PVR during TAVR.

Balloon Aortic Valvuloplasty in the Modern Era: A Review of Outcomes, Indications, and Technical Advances

Balloon aortic valvuloplasty (BAV) improves the hemodynamics and symptoms of patients with severe aortic stenosis in the short term with low rates of complications, but has not been shown to be an effective destination therapy. Our pooled analysis of >14,300 patients from studies published between January 1, 1991, and April 31, 2022, reported intraprocedural mortality and in-hospital mortality rates as 1.94% (95% CI, 1.39%-2.59%) and 6.02% (95% CI, 4.83%-7.32%), respectively. Hence, BAV is primarily indicated as a bridge to aortic valve replacement/decision with secondary uses as bridge to noncardiac surgery and palliative therapy. Recent advancements in alternative access sites, balloon catheters, and lithotripsy for BAV have opened opportunities for expanded use and further improvements in complication rates. As the utilization of BAV has continually increased since the advent of transcatheter aortic valve replacement, reexamining the role and outcomes of BAV in the era of transcatheter aortic valve replacement has become increasingly important. This review focuses on the outcomes, indications, advances, and technical considerations for BAV.

The Impact of Monocyte to High-Density Lipoprotein Cholesterol Ratio on All-Cause and Cardiovascular Mortality in Patients with Transcatheter Aortic Valve Replacement

BACKGROUND

Inflammation plays a significant role in the pathogenesis of aortic stenosis. This study aimed to investigate the prognostic value of the monocyte-HDL cholesterol ratio (MHR), a new inflammatory marker, in severe aortic stenosis (AS) patients who underwent transcatheter aortic valve replacement (TAVR).

METHODS

A total of 125 patients with severe AS who underwent TAVR were assessed. Clinical, echocardiographic and laboratory data relevant to the research were retrospectively obtained from the patients' records. The MHR was determined by dividing the absolute monocyte count by the HDL-C value. The primary endpoints were overall and cardiovascular mortality.

RESULTS

During a median follow-up time of 39 months, primary endpoints were developed in 51 (40.8%) patients (overall mortality) and 21 (16.8%) patients (cardiovascular mortality). A receiver operating characteristic (ROC) analysis showed that by using a cut-off level of 16.16, the MHR predicted the all-cause mortality with a sensitivity of 50.9% and specificity of 89.1%. In predicting cardiovascular mortality, the MHR exhibited a sensitivity of 80.9% and specificity of 70.1% when a cut-off level of 13.56 was used. In the multivariate analysis, the MHR (p < 0.0001; 95% CI: 1.06-1.15) and atrial fibrillation (p = 0.018; 95% CI: 1.11-3.38) were found to be significant predictors of overall mortality.

CONCLUSIONS

This study showed a significant elevation in the MHR among patients who experienced all-cause and cardiovascular mortality and this ratio emerged as an independent predictor of all-cause death in patients with severe AS undergoing TAVR.

Imaging of Bioprosthetic Valve Dysfunction after Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) has become the standard of care in elderly high-risk patients with symptomatic severe aortic stenosis. Recently, TAVI has been increasingly performed in younger-, intermediate- and lower-risk populations, which underlines the need to investigate the long-term durability of bioprosthetic aortic valves. However, diagnosing bioprosthetic valve dysfunction after TAVI is challenging and only limited evidence-based criteria exist to guide therapy. Bioprosthetic valve dysfunction encompasses structural valve deterioration (SVD) resulting from degenerative changes in the valve structure and function, non-SVD resulting from intrinsic paravalvular regurgitation or patient-prosthesis mismatch, valve thrombosis, and infective endocarditis. Overlapping phenotypes, confluent pathologies, and their shared end-stage bioprosthetic valve failure complicate the differentiation of these entities. In this review, we focus on the contemporary and future roles, advantages, and limitations of imaging modalities such as echocardiography, cardiac computed tomography angiography, cardiac magnetic resonance imaging, and positron emission tomography to monitor the integrity of transcatheter heart valves.

Transcatheter aortic valve implantation with different self-expanding devices-a propensity score-matched multicenter comparison

OBJECTIVE

Several supra-annular self-expanding transcatheter systems are commercially available for transcatheter aortic valve implantation (TAVI). Comparative data in large-scale multicenter studies are scant.

METHODS

This study included a total of 5175 patients with severe aortic stenosis undergoing TAVI with the ACURATE neo (n = 1095), Evolut R (n = 3365), or Evolut PRO (n = 715) by a transfemoral approach at five high-volume centers. Propensity score matching resulted in 654 triplets. Outcomes are reported according to the Valve Academic Research Consortium-3 (VARC-3) consensus.

RESULTS

Moderate or severe paravalvular regurgitation (PVR) occurred significantly more often in the ACURATE neo group (5.2%) than in the Evolut R (1.8%) and Evolut PRO (3.3%) groups (p = 0.003). The rates of major vascular-/access-related complications (4.6%, 3.8%, and 5.0%; p = 0.56), type 3 or 4 bleeding (3.2%, 2.1%, and 4.1%; p = 0.12), and 30-day mortality (2.4%, 2.6%, and 3.7%; p = 0.40) were comparable. The rate of new permanent pacemaker implantation (PPI) was significantly lower in the ACURATE neo group (9.5%, 17.6%, and 16.8%; p < 0.001). Independent predictors for 2-year survival were a Society of Thoracic Surgeons (STS) risk score ≥5%, diabetes mellitus, a glomerular filtration rate <30 ml/min, baseline mean transvalvular gradient ≤ 30 mm Hg, treating center, and relevant PVR.

CONCLUSION

In this multicenter study, TAVI with the ACURATE neo, Evolut R, or Evolut PRO was feasible and safe. The rate of relevant PVR was more frequent after the ACURATE neo implantation, with, however, lower rates of PPI. Two-year survival was mainly driven by baseline comorbidities.

Prosthetic Valve Function after Aortic Valve Replacement for Severe Aortic Stenosis by Transcatheter Procedure versus Surgery

Background This study compared the clinical outcomes of transcatheter (TAVR) and surgical (SAVR) aortic valve replacements, focusing on postoperative valvular performance assessed by echocardiography. Method and Results A total of 425 patients who underwent TAVR (230 patients) or SAVR (195 patients) were included. Postoperative effective orifice area index (EOAI) was higher in the TAVR group (1.27 ± 0.35 cm2/m2) than in the SAVR group (1.06 ± 0.27 cm2/m2, p < 0.001), and patient−prosthesis mismatch (PPM) was more frequent in the SAVR group (22.6%) than in the TAVR group (8.7%, p < 0.001). Mild or greater paravalvular leakage (PVL) was more frequent in the TAVR group (21.3%) than in the SAVR group (0%, p < 0.001). Moreover, there was no difference in freedom from all-cause death, stroke, or rehospitalization between the groups. Patients with moderate or greater PPM (EOAI < 0.85 cm2/m2) had lower freedom from composite events than those without this PPM criterion (p = 0.008). Patients with mild or greater PVL also had lower freedom from composite events than those without this PVL criterion (p = 0.017). Conclusions Postoperative valvular performance of TAVR was superior to that of SAVR in terms of EOAI. This merit was counterbalanced by the significantly lower rates of PVL in patients who underwent SAVR. The overall clinical outcomes were similar between the study groups.

Haemodynamic differences between two generations of a balloon-expandable transcatheter heart valve

OBJECTIVES

This study aimed to investigate early haemodynamic and clinical performance of the SAPIEN 3 Ultra (S3 Ultra) transcatheter heart valve (THV) system in comparison to its precursor, the SAPIEN 3 (S3). Previous studies have indicated potential haemodynamic differences between the S3 Ultra and S3. Such differences may impact clinical outcome after transcatheter aortic valve implantation (TAVI).

METHODS

Postprocedural haemodynamic performance and 30-day clinical outcome were compared in patients who underwent TAVI receiving either the S3 or the new S3 Ultra prostheses. Multivariable analysis and propensity score matching (PSM) were used to identify factors associated with higher mean transvalvular gradients.

RESULTS

We included 697 patients (S3 Ultra: n=314, S3: n=383) from the multicentre RhineHeart TAVI Registry. Patients receiving the S3 Ultra prosthesis showed significantly higher postprocedural mean transvalvular gradients (14.2±4.8 vs 10.2±4.4 mm Hg; p<0.01). Multivariable logistic regression analyses and additional PSM revealed the use of the S3 Ultra to be associated with higher postprocedural mean transvalvular gradients (p<0.01). 30-day clinical outcomes, such as mortality, myocardial infarction, permanent pacemaker implantation and vascular complications were comparable between the groups.

CONCLUSIONS

The new S3 Ultra THV was associated with a higher postprocedural mean transvalvular gradient compared with the S3 system, while there was no difference in mortality or adverse clinical outcomes at 30 days. These echocardiographic differences will require long-term studies to assess the clinical relevance of this finding.

Pre-dilation and Post-dilation in Transcatheter Aortic Valve Replacement: Indications, Benefits and Risks

Transcatheter aortic valve replacement (TAVR) is an established treatment for patients with symptomatic severe aortic stenosis. In recent years, an emphasis has been placed on simplification of the procedure. Balloon predilation was initially considered a mandatory step to cross and prepare the stenotic aortic valve, but several studies demonstrated the feasibility of performing TAVR without balloon valvuloplasty. Balloon postdilation of the implanted valve is sometimes required to optimise results, although many patients do not require this step. Contemporary consensus advocates an individualised approach to TAVR procedures and so balloon pre- and post-dilation are performed selectively. This review aims to outline the advantages and disadvantages of balloon pre- and post-dilation and to identify the scenarios in which they are required during TAVR procedures.

Double S-Curve Versus Cusp-Overlap Technique: Defining the Optimal Fluoroscopic Projection for TAVR With a Self-Expanding Device

OBJECTIVES

The purpose of this study was to assess the concordance between transcatheter aortic valve implantation angles generated by the "double S-curve" and "cusp-overlap" techniques.

BACKGROUND

The "double S-curve" and "cusp-overlap" methods aim to define optimal fluoroscopic projections for transcatheter aortic valve replacement (TAVR) with a self-expandable device.

METHODS

The study included 100 consecutive patients undergoing TAVR with self-expanding device planned by multidetector computed tomography. TAVR was performed using the double S-curve model, as a view in which both the aortic valve annulus and delivery catheter planes are displayed perpendicularly on fluoroscopy. Optimal projection according to the cusp-overlap technique was retrospectively generated by overlapping the right and left cups on the multidetector computed tomography annular plane. The angular difference between methods was assessed in spherical 3 dimensions and on the left and right anterior oblique (RAO) and cranial and caudal (CAU) axes.

RESULTS

The double S-curve and cusp-overlap methods provided views located in the same quadrant, mostly the RAO and CAU, in 92% of patients with a median 3-dimensional angular difference of 10.0° (interquartile range: 5.5° to 17.9°). The 3-dimensional deviation between the average angulation obtained by each method was not statistically significant (1.49°; p = 0.349). No significant differences in average coordinates were noted between the double S-curve and cusp-overlap methods (RAO: 14.7 ± 15.2 vs. 12.9 ± 12.5; p = 0.36; and CAU: 27.0 ± 9.4 vs. 26.9 ± 10.4; p = 0.90). TAVR using the double S-curve was associated with 98% device success, low complication rate, and absence of moderate-to-severe paravalvular leak.

CONCLUSIONS

The double S-curve and cusp-overlap methods provide comparable TAVR projections, mostly RAO and CAU. TAVR using the double S-curve model is associated with a high rate of device success and low rate of procedural complications.

Heart failure following transcatheter aortic valve replacement

Introduction: Over the past decade, the number of transcatheter aortic valve replacement (TAVR) procedures has increased exponentially. Despite major improvements in both device and successes, the rate of hospital readmission after TAVR remains high, with heart failure (HF) decompensation being one of the most important causes.Areas covered: This review provides an overview of the current status of HF following TAVR, including details about its incidence, clinical impact, contributing factors, and current and future treatment perspectives.Expert opinion: HF decompensation has been identified as the most common cause of rehospitalization following TAVR, and it has been associated with a negative prognosis. Multiple preexisting factors including low flow status, cardiac amyloidosis, myocardial fibrosis, multivalvular disease, pulmonary hypertension, coronary artery disease, and atrial fibrillation have been associated with an increased risk of HF events. Also, multiple post-procedural factors like the occurrence of significant paravalvular leaks, severe prosthesis-patient mismatch, and conduction disturbances have also contributed to increase this risk . Thus, reducing HF events in TAVR recipients would require a multifactorial and multidisciplinary effort including the optimization of the medical treatment and close follow-up and treatment of residual or concomitant valvular disease and conduction disturbance issues. Future studies in this challenging group of patients are warranted.

How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement

PURPOSE OF REVIEW

In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications.

RECENT FINDINGS

Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.

Aortic valve function post-replacement of severe aortic stenosis by transcatheter procedure versus surgery: a systematic review and metanalysis

Transcatheter aortic valve replacement (TAVR) has shown to reduce mortality compared to surgical aortic valve replacement (sAVR). However, it is unknown which procedure is associated with better post-procedural valvular function. We conducted a meta-analysis of randomized clinical trials that compared TAVR to sAVR for at least 2 years. The primary outcome was post-procedural patient-prosthesis-mismatch (PPM). Secondary outcomes were post-procedural and 2-year: effective orifice area (EOA), paravalvular gradient (PVG) and moderate/severe paravalvular leak (PVL). We identified 6 trials with a total of 7022 participants with severe aortic stenosis. TAVR was associated with 37% (95% CI [0.51–0.78) mean RR reduction of post-procedural PPM, a decrease that was not affected by the surgical risk at inclusion, neither by the transcatheter heart valve system. Postprocedural changes in gradient and EOA were also in favor of TAVR as there was a pooled mean difference decrease of 0.56 (95% CI [0.73–0.38]) in gradient and an increase of 0.47 (95% CI [0.38–0.56]) in EOA. Additionally, self-expandable valves were associated with a higher decrease in gradient than balloon ones (beta = 0.38; 95% CI [0.12–0.64]). However, TAVR was associated with a higher risk of moderate/severe PVL (pooled RR: 9.54, 95% CI [5.53–16.46]). All results were sustainable at 2 years.

The prognostic value of immediate post-TAVI hemodynamic evaluation is superior to aortography and transoesophageal echocardiography in predicting patient survival

BACKGROUND

Although post-TAVI PAR is commonly seen, its exact evaluation, grading and the true impact on patients' survival are still debated. This single center study aimed to evaluate the effect of post transcatheter aortic valve implantation (TAVI) paravalvular aortic regurgitation (PAR) on patients' survival. The outcome was evaluated by the three most commonly used techniques just after TAVI in the interventional arena.

METHODS

201 high risk patients with severe symptomatic aortic stenosis underwent TAVI with the self-expandable system. The severity of post-TAVI PAR was prospectively evaluated by aortography and transesophageal echocardiography (TEE) using a four-class scheme and hemodynamic evaluation by calculation of the regurgitation index (RI). Median follow up time was 763 days.

RESULTS

Post-TAVI PAR results of the three different modalities were concordant with each other (all p < 0.001). Patients with grade 0-I PAR by aortography had better long term outcomes compared to those who had grade II-III PAR (unadjusted HR 1.77 [95% CI, 1.04-3.01], p = 0.03). Although in multivariate analysis neither aortography nor TEE were shown to be significant predictors of survival, hemodynamic assessment using the exact RI result was a significant predictor of survival and its effect was found to be linear (adjusted HR 0.72 [95% CI, 0.52-0.98] for 10% point increase in RI, p = 0.03595).

CONCLUSIONS

Among the three modalities that are frequently used to evaluate the outcome, post-TAVI RI showed the highest added predictive value for survival.

Evolution of outcome and complications in TAVR: a meta-analysis of observational and randomized studies

Aim of the present analysis was to collect and pool all available data currently in the literature regarding outcomes and complications of all approved TAVR prosthesis and to assess the transition from first to next generation TAVR devices by directly comparing both in regard of procedure related complications. Transcatheter aortic valve replacement is a well established treatment modality in patients with severe aortic stenosis deemed to be inoperable or at unacceptable risk for open heart surgery. First generation prostheses were associated with a high rate of peri-procedural complications like paravalvular regurgitation, valve malpositioning, vascular complications and conduction disorders. Refinement of the available devices incorporate features to address the limitations of the first-generation devices. A PRISMA checklist-guided systematic review and meta-analysis of prospective observational studies, national and device specific registries or randomized clinical trials was conducted. Studies were identified by searching PUBMED, SCOPUS, Cochrane Central Register of Controlled Trials and LILACs from January 2000 to October 2017. We extracted and pooled data on both mortality and complications from 273 studies for twelve different valves prostheses in a total of 68,193 patients. In second generation prostheses as compared to first generation devices, we observed a significant decrease in mortality (1.47 ± 1.73% vs. 5.41 ± 4.35%; p < 0.001), paravalvular regurgitation (1.75 ± 2.43vs. 12.39 ± 9.38, p < 0.001) and MACE. TAVR with contemporary next generation devices has led to an impressive improvement in TAVR safety driven by refined case selection, improved procedural techniques and increased site experience.

Management of atrial fibrillation after transcatheter aortic valve replacement: Challenges and therapeutic considerations

Atrial Fibrillation (AF) is very common among patients with severe aortic stenosis. Moreover, new onset AF (NOAF) is a frequent finding after Transcatheter Aortic Valve Replacement (TAVR). There is a significant impact of AF on outcomes in patients undergoing TAVR including mortality, thrombo-embolic and bleeding events. There is lack of clear evidence about the optimal management of AF in TAVR patients. This review aims to summarize the epidemiology, predictors, prognosis, therapeutic considerations and challenges in the management of AF in patients undergoing TAVR.

A validated computational framework to predict outcomes in TAVI

Transcatheter aortic valve implantation (TAVI) still presents complications: paravalvular leakage (PVL) and onset of conduction abnormalities leading to permanent pacemaker implantation. Our aim was testing a validated patient-specific computational framework for prediction of TAVI outcomes and possible complications. Twenty-eight TAVI patients (14 SapienXT and 14 CoreValve) were retrospectively selected. Pre-procedural CT images were post-processed to create 3D patient-specific implantation sites. The procedures were simulated with finite element analysis. Simulations' results were compared against post-procedural clinical fluoroscopy and echocardiography images. The computational model was in good agreement with clinical findings: the overall stent diameter difference was 2.6% and PVL was correctly identified with a post-processing algorithm in 83% of cases. Strains in the implantation site were studied to assess the risk of conduction system disturbance and were found highest in the patient who required pacemaker implantation. This study suggests that computational tool could support safe planning and broadening of TAVI.

Performance of the CoreValve Evolut R and PRO in Severely Calcified Anatomy: A Propensity Score Matched Analysis

BACKGROUND

The CoreValve Evolut R and PRO (Medtronic, Minneapolis, MN, USA) are among the newest-generation of self-expandable transcatheter aortic valve replacement (TAVR) devices and show excellent results. Treating patients with severely calcified (SC) native aortic valve anatomy may be challenging because of the increased risk of periprocedural complications. This study investigated the performance of Evolut R and PRO in this special patient subset.

METHODS

Patients who underwent TAVR with the CoreValve Evolut R or PRO (n=381) from September 2015 to March 2018 were divided by aortic valve calcification extent. Patients with SC aortic valve anatomy (n=98; men, >2,062 and women, >1,377 Agatston units) were compared with those with non-severely calcified (NCS) aortic valve anatomy after 1:2 propensity score matching. Outcomes were evaluated according to the updated valve academic research consortium criteria.

RESULTS

Patients with SC anatomy were older (83 years vs 80 years, p<0.001) and had a smaller aortic valve area (0.63 cm² vs 0.70 cm², p=0.028). Pre-dilatation was more often performed (30.6% vs 15.8%, p=0.003) and a permanent pacemaker implantation was more often necessary (32.9% vs 8.8%, p<0.001) in the SC group. None/mild aortic regurgitation (AR) was evenly distributed (SC, 96.9% vs NCS, 99.5%, p=0.109); moderate AR was present in 3.1% of SC patients and in 0.5% of NSC patients. Severe AR was not observed.

CONCLUSION

The CoreValve Evolut R and PRO showed good clinical safety profiles and excellent haemodynamic results in patients with SC anatomy and who more often required permanent pacemaker implantation.

Transcatheter aortic valve implantation via surgical subclavian versus direct aortic access: A United Kingdom analysis

BACKGROUND

Surgical subclavian (SC) and direct aortic (DA) access are established alternatives to the default transfemoral route for transcatheter aortic valve implantation (TAVI). We sought to find differences in survival and procedure-related outcomes after SC- versus DA-TAVI.

METHODS

We performed an observational cohort analysis of cases prospectively uploaded to the UK TAVI registry. To ensure the most contemporaneous comparison, the analysis focused on SC and DA procedures performed from 2013 to 2015.

RESULTS

Between January 2013 and July 2015, 82 (37%) SC and 142 (63%) DA cases were performed that had validated 1-year life status. Multivariable regression analysis showed procedure duration was longer for SC cases (SC 193.5 ± 65.8 vs. DA 138.4 ± 57.7 min; p < .01) but length of hospital stay was shorter (SC 8.6 ± 9.5 vs. DA 11.9 ± 10.8 days; p = .03). Acute kidney injury was observed less frequently after SC cases (odds ratio [OR] 0.35, 95% confidence interval [CI 0.12-0.96]; p = .042) but vascular access site-related complications were more common (OR 9.75 [3.07-30.93]; p < .01). Procedure-related bleeding (OR 0.54 [0.24-1.25]; p = .15) and in-hospital stroke rate (SC 3.7% vs. DA 2.1%; p = .67) were similar. There were no significant differences in in-hospital (SC 2.4% vs. DA 4.9%; p = .49), 30-day (SC 2.4% vs. DA 4.2%; p = .71) or 1-year (SC 14.5% vs. DA 21.9%; p = .344) mortality.

CONCLUSIONS

Surgical subclavian and direct aortic approaches can offer favourable outcomes in appropriate patients. Neither access modality conferred a survival advantage but there were significant differences in procedural metrics that might influence which approach is selected.

Comparison of the self-expanding Evolut-PRO transcatheter aortic valve to its predecessor Evolut-R in the real world multicenter ATLAS registry

BACKGROUND

The Evolut PRO self-expanding transcatheter aortic valve has been designed to feature an outer pericardial wrap that aims to reduce paravalvular regurgitation (PVR) rates. Medium-term clinical outcomes, compared to its predecessor Evolut R, in a real-world setting, have not been investigated. The aim of the present study was to compare the two valves with regards to peri-procedural complications, early outcomes and mid-term survival.

METHODS

Consecutive patients, undergoing TAVI with either the Evolut PRO or Evolut R device, from the multicenter ATLAS registry were retrospectively studied. Outcomes studied included periprocedural complications, PVR at discharge, need for new pacemaker implantation and Kaplan-Meier estimated 1-year all-cause mortality.

RESULTS

Analysis included 673 patients (498 treated with Evolut R and 175 treated with Evolut PRO). At least moderate PVR was numerically lower amongst patients treated with Evolut PRO (7.4% vs 3.8% for Evolut R and Evolut PRO respectively, p = .108). Rates of new permanent pacemaker (PPM) implantation (21.1% vs. 11.9%, p = .023), and bail-out valve-in-valve (2.4% vs. 0%, p = .049) were significantly lower amongst the Evolut PRO group. No differences were demonstrated regarding bleeding, stroke or acute kidney injury. One-year Kaplan-Meier estimated survival was similar between groups (93% for Evolut R vs. 91.2% for Evolut PRO, p_log-rank = 0.806).

CONCLUSIONS

The Evolut PRO self-expanding valve demonstrates similar mid-term survival rates and numerically, yet not significant, lower incidence of PVR compared to its predecessor. Interestingly this new generation valve is associated with a significantly reduced rate for new PPM implantation. Future studies are required to confirm this finding.

Transcatheter Aortic Valve Replacement Valve in Transcatheter Aortic Valve Replacement Valve for Severe Periprosthetic Regurgitation

The management of postprocedure severe aortic periprosthetic regurgitation after transcatheter aortic valve replacement (TAVR) is unknown. While valve-in-valve TAVR has been associated with favorable outcomes for degenerative surgically implanted bioprosthetic valves, there are no evidence-based guidelines for immediate TAVR valve in TAVR valve for periprosthetic regurgitation. We present a patient who underwent a TAVR valve in TAVR valve implantation within 48 h of her first procedure and showed a good response.

Plugging Paravalvular Leak in Transcatheter Aortic Valves

Paravalvular leak can complicate transcatheter aortic valve replacement with important prognostic implications. Correction of defects requires complex planning and execution. Multiple or irregular lesions, calcified annulus, and high sealing skirts on self-expandable devices are especially challenging. Such defects may be approximated using malleable vascular closure devices. (Level of Difficulty: Intermediate.)

Early detection of transcatheter heart valve dysfunction

Introduction: Transcatheter aortic valve implantation therapy is spreading rapidly, representing the standard of care in inoperable and high-risk patients, and a valid alternative in intermediate- and low-risk patients with severe symptomatic aortic stenosis. In this subset, the development and validation of noninvasive, quantitative, in vivo imaging modality, to monitor possible valve dysfunction is mandatory, in order to plan timely therapeutic interventions before the onset of symptoms.Areas covered: The implantation of transcatheter heart valves (THV) is increasing rapidly. As a consequence, THV dysfunction will become a major cause of cardiovascular morbidity after TAVI. Emergency repeat aortic valve replacement surgery is associated with a high rate of mortality compared with elective repeat surgery. In this context, early detection of THV dysfunction is therefore highly desirable. The review aims to examine the different diagnostic method to early detect THV dysfunction.Expert opinion: Most promising innovations in the diagnosis of early detection of THV dysfunction are evaluated, and the future outlook is explored. Waiting for upcoming evidence about the utility of CT, CMR, and PET on early detection of THV dysfunction, tailoring echocardiogram follow-up based on patients' characteristics is the desirable approach.

Immersogeometric fluid-structure interaction modeling and simulation of transcatheter aortic valve replacement

The transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative to surgical treatments of valvular heart disease. TAVR offers many advantages, however, the safe anchoring of the transcatheter heart valve (THV) in the patients anatomy is key to a successful procedure. In this paper, we develop and apply a novel immersogeometric fluid-structure interaction (FSI) framework for the modeling and simulation of the TAVR procedure to study the anchoring ability of the THV. To account for physiological realism, methods are proposed to model and couple the main components of the system, including the arterial wall, blood flow, valve leaflets, skirt, and frame. The THV is first crimped and deployed into an idealized ascending aorta. During the FSI simulation, the radial outward force and friction force between the aortic wall and the THV frame are examined over the entire cardiac cycle. The ratio between these two forces is computed and compared with the experimentally estimated coefficient of friction to study the likelihood of valve migration.

Multicentre propensity-matched comparison of transcatheter aortic valve implantation using the ACURATE TA/neo self-expanding versus the SAPIEN 3 balloon-expandable prosthesis

AIMS

In the absence of randomised data, we aimed to compare the transapical ACURATE and transfemoral ACURATE neo with the SAPIEN 3 prosthesis using propensity matching.

METHODS AND RESULTS

From 2012 to 2016, 1,306 patients at three German centres received either the ACURATE/ACURATE neo prosthesis (n=591) or the SAPIEN 3 prosthesis (n=715). Through nearest neighbour matching with exact allocation for access route and centre, pairs of 329 patients (250 transfemoral, 79 transapical) per group were determined. Patients were 81 years old on average and had a logistic EuroSCORE I of 19%. Predilatation and post-dilatation were more frequent in the ACURATE group (97.6% versus 52.1%, p<0.001 for predilatation and 40.4% versus 11.6%, p<0.001 for post-dilatation), but rapid pacing for implantation was used less frequently (37.1% versus 98.2%, p<0.001). More-than-mild aortic regurgitation at postoperative echocardiography was 12.0% for the ACURATE group and 3.1% for the SAPIEN group, p≤0.001). More-than-mild aortic regurgitation in the ACURATE group differed amongst the centres with 6.0% (3/50) in centre A, 34.1% (29/85) in centre B and 3.4% (6/181) in centre C. Patients in the ACURATE group less frequently had pacemaker implantation compared to the SAPIEN 3 group (11.9% versus 18.5%, p=0.020), 30-day mortality was 4.6% versus 2.1%, respectively, p=0.134, and one-year survival was 83.1% (95% CI: 77.6-87.4) versus 88.8% (95% CI: 84.0-92.2).

CONCLUSIONS

In this propensity score analysis, patients treated with the transapical ACURATE or transfemoral ACURATE neo prosthesis less frequently had pacemakers at 30 days but had more aortic regurgitation and lower one-year survival.

Transcatheter Aortic Valve Replacement: Procedure and Outcomes

Initially, transcatheter aortic valve replacement (TAVR) was only used in patients with severe symptomatic aortic stenosis and prohibitive risk for surgical aortic valve replacement. Subsequently, TAVR was extended to patients with high and intermediate surgical risk. Recently, the results of randomized trials in low-surgical-risk patients showed superiority or noninferiority of TAVR versus surgical aortic valve replacement in this population. Procedural outcomes have been improved. Long-term durability of transcatheter heart valves remains to be confirmed. This article presents the evolution and current status of TAVR, with respect to the different types of devices and procedures as well as its outcomes.

Comparison of transthoracic and transesophageal echocardiography for transcatheter aortic valve replacement sizing in high-risk patients

BACKGROUND

Untreated symptomatic high-grade aortic stenosis remains a lethal disease requiring individually adapted valve replacement. High-risk surgical patients benefit from transcatheter aortic valve replacement (TAVR), but there is no uniform standard for patient selection and valve sizing and it is still unclear whether transthoracic (TTE) or transesophageal (TEE) echocardiography is superior in preprocedural aortic annulus sizing. As preprocedural sizing of the native aortic annulus diameter is crucial to outcome and survival, we report the results of a direct comparison between preprocedural sizing with TTE and TEE including subsequent outcomes in a high-risk TAVR population.

METHODS

A total of 149 TAVR patients were enrolled for TTE and TEE comparison, and an additional 15 patients without structural heart disease were investigated as control group to determine the influence of aortic valve calcification on TTE and TEE aortic annulus diameter measurements.

RESULTS

Overall standardized TTE and TEE measurements for aortic annulus sizing showed excellent correlation at good image quality (p < 0.01, r = 0.934). Calcification of the aortic annulus diameter was not found to exert a noteworthy negative influence on measurements for both standardized TTE and TEE and complication rates did not differ for mortality, periprocedural stroke and paraprosthetic regurgitation.

CONCLUSIONS

Transthoracic echocardiography and TEE are both equally suitable methods of preprocedural aortic annulus size evaluation in preparation of TAVR procedures.

Time-Integrated Aortic Regurgitation Index Helps Guide Balloon Postdilation During Transcatheter Aortic Valve Replacement and Predicts Survival

Background

Balloon postdilation (BPD) has emerged as an effective strategy to reduce paravalvular regurgitation (PVR) during transcatheter aortic valve replacement (TAVR). We investigated the utility of a time‐integrated aortic regurgitation index (TIARI) to guide balloon postdilation (BPD) after valve deployment.

Methods and Results

All consecutive patients who had echocardiography, aortography, and hemodynamic tracings recorded immediately after valve deployment during TAVR were included in the study. Catheter‐derived invasive hemodynamic parameters were calculated offline. Among 157 patients who underwent TAVR, 49 (32%) patients required BPD to reduce significant PVR after valve deployment. Two experienced operators decided whether the patients required BPD for significant PVR. Median TIARI measured immediately after valve deployment was significantly lower in patients who required BPD when compared with patients who did not require BPD (P<0.001). In a multivariable analysis, lower TIARI (odds ratio: 0.81; P=0.003) and higher PVR grade on aortography and echocardiography (P<0.001 for both) were associated with BPD. Adding TIARI to echocardiography and aortographic PVR assessment resulted in a significant increase in global χ² (P<0.001), an integrated discrimination index of 9% (P=0.002), and combined C‐statistics of 0.99 for predicting BPD. Higher TIARI after valve deployment was associated with better survival (hazard ratio: 0.94, P=0.014), while other hemodynamic and imaging parameters did not predict mortality after TAVR.

Conclusions

Among patients undergoing TAVR, a TIARI measured immediately after valve deployment adds incremental value to guide BPD over aortography and echocardiography. Higher residual TIARI is associated with better survival after TAVR.

Intraprocedural valve-in-valve deployment for treatment of aortic regurgitation following transcatheter aortic valve replacement: An individualized approach

BACKGROUND

Aortic regurgitation (AR) following transcatheter aortic valve replacement (TAVR) is usually due to paravalvular leak, is more common with self-expanding valves and is associated with adverse outcomes. Treatment of AR with a second valve (valve-in-valve) has been reported, however the mechanism of benefit is unclear. We hypothesized that location of the initial valve in relation to the aortic annulus should guide positioning of the second valve.

METHODS

We assessed the outcomes of valve-in-valve deployment for treatment of AR following implantation of self-expanding valves in a single-center TAVR registry. Location of the initial valves was defined as supra-annular, intra-annular or infra-annular according to the position of the device pericardial skirt relative to the annulus. Positioning of the second valve was selected according to the location of the initial valves.

RESULTS

Among 285 TAVR patients who received Corevalve or Evolut-R valves, 11 (3.8%) underwent valve-in-valve deployment due to AR. Position of initial valves was supra-annular in 6 cases (group-1), intra-annular in 3 cases (group-2) and infra-annular in 2 cases (group-3). In group-1, second valves were implanted 9 ± 4 mm lower than the initial valves. In group-2, second valves were implanted 7 ± 4 mm higher than the initial valves. In group-3, second valves were implanted 9 ± 1 mm higher than the initial valves. Valve-in-valve deployment reduced AR grade in all 3 groups.

CONCLUSIONS

Valve-in-valve deployment decreased AR grade during TAVR procedures. We suggest that positioning of the second valve should be guided by the location of the initial valve relative to the aortic annulus.

Radial Force: An Underestimated Parameter in Oversizing Transcatheter Aortic Valve Replacement Prostheses: In Vitro Analysis with Five Commercialized Valves

The goal is to inform in depth on transcatheter aortic valve replacement (TAVR) prosthesis mechanical behavior, depending on frame type, design, and size, and how it crucially impacts the oversizing issue in clinical use, and ultimately the procedure outcome. Transcatheter aortic valve replacement is an established therapy for high-risk patients suffering from aortic stenosis, and the indication for TAVR is progressively expanding to intermediate-risk patients. Choosing the optimal oversizing degree is crucial to safely anchor the TAVR valve-which involves limiting the risks for embolism, aortic regurgitation, conductance disturbance, or annulus rupture-and to increase the valve prosthesis performance. The radial force (RF) profiles of five TAVR prostheses were measured in vitro: the CoreValve 23 and 26 (Medtronic, Minneapolis, MN), the Acurate neo S (Symetis, Écublens, Vaud, Switzerland), and the SAPIEN XT 23 and 26 (Edwards Lifesciences, Irvine, CA). Measurements were run with the RX Machine equipment (Machine Solutions Inc., Flagstaff, AZ), which is used in ISO standard tests for intravascular stents. Test protocols were adapted for TAVR prostheses. With the prostheses RF profiles' results, mechanical behavior differences could be described and discussed in terms of oversizing strategy and clinical impact for all five valves. Besides, crossing the prostheses' RF profiles with their recommended size windows made the assessment of borderline size cases possible and helped analyze the risks when accurate measurement of patient aortic annulus proves difficult. The prostheses' RF profiles bring new support in clinical decision-making for valve type and size in patients.

Left Ventricular Diastolic Dysfunction and Transcatheter Aortic Valve Replacement Outcomes: A Review

Aortic stenosis (AS) is the most common valvular disease that can lead to increased afterload, left ventricular (LV) remodeling, and myocardial fibrosis. We reviewed the literature addressing the impact of transcatheter aortic valve replacement (TAVR) on LV remodeling and patients' outcomes by elimination of AS-related high afterload. TAVR reduces afterload and improves LV remodeling recovery. However, myocardial fibrosis may not completely reverse after the TAVR. The LV diastolic dysfunction (LVDD) induced by AS is an independent predictor of post-TAVR mortality, and mortality increases with severity of LVDD. The impact of diastolic dysfunction on patient outcomes emerges at 30 days but continues to persist during mid-term follow-up. Based on severity of the baseline LVDD, some patients may tolerate post-TAVR aortic regurgitation (AR), but even minimal post-TAVR AR in patients with severe baseline LVDD can have an additive negative impact on survival. It is crucial to consider TAVR prior to development of advanced LVDD. Appropriate device selection and deployment technique are important in improvement of TAVR outcomes via elimination of AR.

Transcatheter aortic valve replacement in atypical valve anatomy using the Lotus valve : A Chinese single-center experience

BACKGROUND

In the West, the safety and efficacy of the Lotus valve have been demonstrated; however, data in the Chinese population are still lacking. Few studies have compared the clinical outcomes of transcatheter aortic valve replacement (TAVR) with the Lotus valve in patients with bicuspid or tricuspid aortic valve stenosis. Our aim was to assess TAVR outcomes with the Lotus aortic valve in a Chinese patient cohort.

METHODS

In total, 23 symptomatic, high-surgical risk patients with severe aortic valve stenosis were enrolled. Among them, nine patients (39%) had bicuspid aortic valves, and three patients had a large annulus dimension. The Lotus valve was successfully implanted in all patients. To facilitate accurate positioning, partial re-sheathing was attempted in ten patients (43.5%), while one patient had a full retrieval. One-year clinical follow-up was completed in all patients.

RESULTS

There were no deaths, strokes, or major adverse cardiac and cerebrovascular events in 22 of the 23 patients at 30 days; the all-cause mortality rate at 1 year was 4.4% (1 of 23 patients). The mean aortic valve gradient decreased from 51.5 ± 8.8 mm Hg at baseline to 13.4 ± 4.9 mm Hg (p < 0.001) and the valve area increased from 0.6 ± 0.2 cm² to 1.5 ± 0.4 cm² (p < 0.001) at 30 days. Paravalvular leakage was absent or mild (22%), and no patient had severe paravalvular leakage. Six patients (26.1%) required a postprocedural pacemaker. There was no difference regarding the procedural and the 1‑year outcomes between patients with bicuspid and tricuspid aortic valve stenosis.

CONCLUSION

Our single-center experience demonstrated that the Lotus valve is feasible and effective for Chinese patients with aortic valve stenosis, including atypical cases with bicuspid aortic valves or large aortic annulus size.

Comparative survival and role of STS score in aortic paravalvular leak after SAVR or TAVR: a retrospective study from the USA

OBJECTIVE

The presence of aortic paravalvular leak (PVL) is associated with lower survival, but a direct comparison of its impact after transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) has not been performed. This study sought to determine the differential influence of PVL on survival following TAVR versus SAVR and in patients with varying levels of risk as defined by the Society of Thoracic Surgeons (STS) risk score.

METHODS

Patients with and without postprocedural PVL were identified from 2290 patients undergoing TAVR or SAVR at Mayo Clinic between 2008 and 2014. The primary endpoint was overall survival.

RESULTS

There were 588 patients with PVL (374 TAVR, 214 SAVR): age 78±11 years, 63% male and mean follow-up of 3±2 years. PVL was trivial/mild in 442 (75%) patients. In propensity-matched analyses (n=86 per group), the overall survival at 1 and 4 years was 93% and 56% vs 89% and 61% in patients with PVL after TAVR versus SAVR, respectively (p=0.43). The presence or degree of PVL severity had no influence on survival of patients with high STS score (≥8%), while the presence of greater than mild PVL predicted worse survival in those with STS score <8%. During the first year after PVL diagnosis, while either improvement or stable PVL grade was seen in the majority of patients, worsening of PVL grade was more common in the TAVR group (19%) versus the SAVR group (4%) (p<0.0001).

CONCLUSIONS

At mid-term follow-up, the presence of PVL was associated with equally unfavourable outcomes following SAVR or TAVR. In patients with high STS risk score, the presence of PVL was not independently associated with increased mortality.