First-in-Human Multicenter Experience of the Newest Generation Supra-Annular Self-Expanding Evolut FX TAVR System

Platform Selection for Patients Undergoing Transcatheter Aortic Valve Replacement: A Practical Approach

Transfemoral transcatheter aortic valve Replacement (TAVR) has become the standard therapy for patients with severe aortic stenosis in patients over 75 years old in Europe or 65 years old in the United States, regardless of the surgical risk. Furthermore, iterations of existing transcatheter aortic valves (TAVs), as well as devices with novel concepts, have provided substantial improvements with respect to the limitations of previous-generation devices. Hence, treatment of a broader spectrum of patients has become feasible, and a sophisticated selection of the appropriate TAV tailored to patients' anatomy and comorbidities is now possible. Anatomy, patient characteristics, and operator experience must all inform proper device selection. This review describes the features and performance of the current generation of TAVs with the aim of providing a practical approach for clinicians when selecting the appropriate TAV for a specific patient.

Predictors of permanent pacemaker requirement in aortic stenosis patients undergoing self-expanding valve transcatheter aortic valve replacement using the cusp overlap technique

Introduction

Since TAVR was approved for lower-risk aortic stenosis (AS) patients, managing post-implantation conduction disturbances has become crucial, especially with self-expanding heart valves (SEV). This study aims to identify risk factors for conduction disturbances in such patients using a specific fluoroscopic cusp overlap (COL) technique.

Methods

This retrospective study analyzed AS patients who underwent TAVR with SEV from 2019 to 2022, excluding those needing pacemakers or valve-in-valve procedures. Patients were grouped by conventional (CON) and COL techniques, with outcomes monitored using Valve Academic Research Consortium (VARC)-2 criteria.

Results

In this cohort study of 114 patients, 17 were excluded due to pre-existing pacemakers. Forty-seven received SEVs using COL, and 50 with CON techniques. The COL group showed a significant reduction in new LBBB (27.7% vs. 46%, p = 0.006) and PPI rates (4.3% vs. 18%, p = 0.033) compared to the CON group. Deeper implantation depth below the non-coronary cusp (NCC) and left coronary cusp (LCC) was linked to an increased risk of conduction disturbances. Multivariate analysis identified smaller left ventricular outflow tract diameter, shorter membranous septum length, and greater pre-releasing implantation depth below the LCC as predictors of future PPI risk.

Conclusion

The use of the COL technique significantly reduces the risk of newly developed conduction disturbances after SEV TAVR. Keeping SEV implantation depth within 1 mm of the membranous septum length and maintaining an implantation depth of <6 mm below the LCC before final release further minimizes the risk of PPI.

Initial Findings Concerning the Latest Self-Expandable Evolut FX Valve: A Report Using OCEAN-TAVI Registry Data

Data concerning the clinical effect of the latest-generation self-expandable transcatheter heart valve (Evolut FX) remain limited. We aimed to assess the in-hospital outcomes of 3 bioprosthetic valves (Evolut EPO, PRO+, and FX). We analyzed data from a Japanese multicenter registry involving 634 consecutive patients who underwent transcatheter aortic valve replacement with Evolut FX up until October 2023. Patients who underwent transcatheter aortic valve replacement with Evolut EPO between 2018 and 2020 (n = 1,128), and those with Evolut EPO+ between 2020 and 2023 (n = 1,696) served as the control groups. The exclusion criteria comprised patients on dialysis with a history of infective endocarditis or with insufficient data. Unmatched comparisons among the 3 valves were conducted, followed by a propensity score-matched comparison between Evolut EPO+ and FX. In the unmatched cohort, among the Evolut EPO, PRO+, and FX groups, all vascular complications (7.8% vs 5.2% vs 4.5%, respectively, p <0.01) and new pacemaker implantation rates (11.2% vs 6.1% vs 7.7%, respectively, p <0.01) differed significantly. In the propensity score-matched analysis, the rate of all bleeding events was significantly higher in the Evolut EPO+ group (11.0%) than in the FX group (7.0%) (p = 0.02), whereas all vascular complications (4.6% vs 4.6%, respectively, p = 1.00) and new pacemaker implantation (5.9% vs 7.6%, respectively, p = 0.28) rates were comparable. The incidence of stroke in the FX group was approximately half that of the EP+ group (3.7% vs 1.9%, p = 0.095), without statistical significance. In conclusion, compared with the Evolut EPO+, Evolut FX was associated with a lower incidence of in-hospital bleeding complications and may reduce the incidence of in-hospital stroke.

Initial Multicenter Experience With a Novel Self-Expanding TAVR System in Patients With Aortic Valve Stenosis

BACKGROUND

As transcatheter aortic valve replacement is performed increasingly in younger, low-risk patients, the need for commissural alignment and coronary access has increased. Design elements of the JenaValve Trilogy (JVT) transcatheter heart valve (THV) ensure both.

OBJECTIVES

This study sought to evaluate the outcome of patients with aortic stenosis (AS) treated with this novel transfemoral, self-expanding THV.

METHODS

We included 43 consecutive patients with severe AS treated with the JVT system at 5 German sites. The primary endpoint of the study was technical success of the procedure. Procedural outcomes, hemodynamic valve performance, and clinical outcomes at 30 days were evaluated according to the Valve Academic Research Consortium-3 criteria.

RESULTS

The median age was 81 years (Q1-Q3: 77.0-83.9 years) with a median Society of Thoracic Surgeons Risk Score of 3.1% (Q1-Q3: 2.1%-5.9%). Technical success was achieved in 98% (n = 42 of 43). One patient was converted to open surgery. The median aortic gradient was 5.0 mm Hg (Q1-Q3: 4.0-7.0 mm Hg), and no patient had moderate or greater paravalvular regurgitation (88% [n = 37 of 42] with none or trace paravalvular regurgitation). At 30 days, major vascular complications and stroke each occurred in 1 (2.3%) patient, 2 (4.7%) patients had died, and permanent pacemaker implantation was needed in 4.9% (n = 2 of 41). Overall, early safety at 30 days was achieved in 82% (n = 27 of 33) of patients.

CONCLUSIONS

Treatment of AS patients with this novel transfemoral THV system is safe and effective. The JVT offers an excellent alternative to established transcatheter aortic valve replacement prostheses for patients with AS.

Raphe-Type Bicuspid Aortic Valve as a Risk Factor for Transcatheter Aortic Valve Replacement Failure: Improving Outcomes Using the LIRA Method and the Medtronic FX Prosthesis

Transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis and raphe-type bicuspid aortic valve (BAV) is still associated with poor outcomes in terms of increased risk of paravalvular regurgitation, stroke, and permanent pacemaker implantation. There is no definitive consensus on the optimal sizing method for prosthesis selection in this setting. The LIRA method is a supra-annular tailored sizing method specifically designed for bicuspid anatomy that might increase accuracy of prosthesis choice in BAV patients and improve TAVR outcomes. This is the first report of the combination of the novel LIRA method for prosthesis sizing together with the adoption of the technological improvements introduced by the Evolut FX prosthesis as a useful tool for improving outcomes in this high risk subgroup of patients.

Conduction Disturbances After Transcatheter Aortic Valve Replacement: An Update on Epidemiology, Preventive Strategies, and Management

Conduction disturbances (CDs) are common after transcatheter aortic valve replacement. Continuous improvements in preprocedural planification, implant techniques, and device design have markedly reduced periprocedural complications. However, CDs rate remains in the double-digit range. Because CDs after TAVR are associated with poorer outcomes, seeking a reduction in their occurrence is paramount. Several nonmodifiable and modifiable factors are associated with an increased risk of CDs. Previous right bundle branch block has been shown to have a strong association with pacemaker implant after TAVR. Among the modifiable factors, a lower implantation depth seems to be associated with a higher risk of CDs, and several implant strategies aiming to obtain a higher implant depth have shown promising results. This literature review provides a detailed description of updated evidence about the epidemiology, impact, and preventive and management strategies of CDs after TAVR. Also, based on these updated data, a fast-track protocol CDs management is proposed.

Impact of commissural alignment on the hemodynamic performance of supra-annular self-expandable transcatheter aortic valves

BACKGROUND

Hemodynamic impact of commissural alignment (CA) with self-expandable transcatheter aortic valves (TAVR) has not been investigated yet.

AIMS

To determine hemodynamic impact of CA with self-expandable TAVR.

METHODS

Multicentric ambispective study comparing patients who underwent self-expandable TAVR in seven centers with the Evolut Pro/Pro+ (EP) (Medtronic) and Acurate neo2 (AN2) (Boston Scientific) with and without CA strategies. The degree of commissural misalignment (CMA) was assessed by computed tomography/angiography and 1-year transvalvular gradients/regurgitation evaluated by echocardiography. A matched comparison according to annular dimensions/eccentricity, prosthesis size/type, and baseline left ventricular function and gradients was performed.

RESULTS

A total of 557 patients, mean age 80.7 ± 6.6 years, 61.4% men, and STS score of 4.3 ± 3.1% were analyzed. A CA technique was attempted in 215 patients (38.6%), including 113 patients with AN2 and 102 patients with EP. None/mild CMA was found in 158 (73.5% vs. 43.6% if no CA attempted, p < 0.001) with no differences between devices (AN2:75.2%; EP:71.6%, p = 0.545). Patients with moderate/severe CMA had a greater aortic peak gradient (22.3 ± 8.7 vs. 19.7 ± 8.5, p = 0.001), significantly greater progression of both peak (p = 0.002) and mean gradients (p = 0.001) after matching, and higher rate of central aortic regurgitation (1.2% vs. 0.4%, p = 0.005) at 1-year, but not a greater proportion of patients with mean gradient ≥ 10 mmHg.

CONCLUSIONS

The use of CA strategies significantly reduced the rate of CMA for the self-expandable TAVR devices ACN2 and EP which was associated to lower transvalvular gradients and intra-prosthetic regurgitation progression at 1-year although no criteria of structural deterioration were met at this follow up.

CLINICALTRIALS

org: NCT05097183.

CT-Derived Patient-Specific Computer Simulation of the Novel Self-Expanding Evolut FX Implantation: A Case Series

Background/Objectives: Paravalvular leak and permanent pacemaker implantation remain relevant issues after transcatheter aortic valve implantation (TAVI). Novel device development as well as adequate preprocedural device selection can contribute to optimal outcomes. Methods: Computed tomography-based patient-specific computer anatomical analysis and simulation were used in addition to standard preprocedural preparation in three of the first Evolut FX cases in our center. Procedural and follow-up echocardiographic outcomes are presented. Results: Computed tomography-based computer simulation of Evolut FX resulted in implantation of a different size in one of three cases. In three cases of severe aortic valve stenosis, procedural as well as follow-up outcomes were satisfactory and in line with the simulated results of the chosen strategy. Conclusions: Preprocedural patient-specific computer simulation predicts and guides decision-making in TAVI with the Evolut FX platform. The combination of advanced preprocedural technology and novel technologies continues to contribute to the optimization of TAVI outcomes.

Use and performance of the evolut FX transcatheter aortic valve system

BACKGROUND

The next generation supra-annular, self-expanding Evolut FX transcatheter aortic valve (TAV) system was designed to improve catheter deliverability, provide stable and symmetric valve deployment, and assess commissural alignment during the procedure. The impact of these modifications has not been clinically evaluated.

METHODS

Procedural information was collected by survey in 2 Stages: Stage I comprised 23 centers with extensive experience with Evolut TAV systems, and Stage II comprised an additional 46 centers with a broad range of balloon- and self-expanding system experience. Operators were to compare the experience with the Evolut FX to the predicate Evolut PRO+ system.

RESULTS

There were 285 cases during Stage I from June 24 to August 12, 2022, and 254 cases during Stage II from August 15 to September 11, 2022. Overall, the cusp overlap technique was used in 88.6 %, and commissural alignment was achieved in 96.1 % of these cases. Compared to implanter's previous experience with the Evolut PRO+ system, less resistance was noted with the Evolut FX system: in 83.0 % of cases during vascular insertion, in 84.7 % of cases while tracking through the vasculature, in 84.4 % of cases while traversing over the arch, and 76.1 % of cases in advancing across the valve. Better symmetry of valve depth was observed in 423 of 525 cases (80.6 %).

CONCLUSION

Evolut FX system design modifications translated into improvements in catheter deliverability, deployment symmetry and stability, and commissural alignment as assessed by experienced self-expanding and balloon expandable operators.

Transcatheter Aortic Valve Implantation Using the Evolut FX+ Platform With Optimal Diamond-Coronary Alignment

We present one of the inaugural transcatheter aortic valve implantation procedures using the latest Medtronic platform, Evolut FX+. Successful coronary angiography was achieved within 28 seconds and 1 minute 49 seconds for the left and right coronary arteries, respectively. Postoperative cardiac computed tomography scan demonstrated optimal commissural and diamond-coronary alignment.

Outcomes of Transcatheter Aortic Valve Replacement Using Third-Generation Balloon-Expandable Versus Self-Expanding Valves: A Meta-analysis

Background

The choice of transcatheter aortic valve replacement (TAVR) prosthesis is crucial in optimizing short- and long-term outcomes. The objective of this study was to conduct a meta-analysis comparing outcomes of third-generation balloon-expandable valves (BEV) vs self-expanding valves (SEV).

Methods

Electronic databases were searched from inception to June 2023 for studies comparing third-generation BEV vs SEV. Primary outcome was all-cause mortality. Secondary outcomes included clinical and hemodynamic end points. Random-effects models were used to calculate pooled odds ratios (ORs) or weighted mean differences (WMDs).

Results

The meta-analysis included 16 studies and 10,174 patients (BEV, 5753 and SEV, 4421). There were no significant differences in 1-year all-cause mortality (OR, 1.15; 95% CI, 0.89-1.48) between third-generation BEV vs SEV. TAVR with third generation BEV was associated with a significantly lower risk of TIA/stroke (OR, 0.62; 95% CI, 0.44-0.87), permanent pacemaker implantation (OR, 0.55; 95% CI, 0.44-0.70), and ≥moderate paravalvular leak (PVL, OR, 0.43; 95% CI, 0.25-0.75), and higher risk of ≥moderate patient-prosthesis mismatch (OR, 3.76; 95% CI, 2.33-6.05), higher mean gradient (WMD, 4.35; 95% CI, 3.63-5.08), and smaller effective orifice area (WMD, -0.30; 95% CI, -0.37 to -0.23), compared with SEV.

Conclusion

In this meta-analysis, TAVR with third-generation BEV vs SEV was associated with similar all-cause mortality, lower risk of TIA/stroke, permanent pacemaker implantation, and ≥moderate PVL, but higher risk of ≥moderate patient-prosthesis mismatch, higher mean gradient, and smaller effective orifice area. Large, adequately powered randomized trials are needed to evaluate long-term outcomes of TAVR with latest generations of BEV vs SEV.

Safety and effectiveness of the novel Myval Octacor transcatheter heart valve in severe, symptomatic aortic valve stenosis - A real-world Indian experience (The OCTACOR India Study)

PURPOSE

To evaluate the safety and effectiveness of the novel, next-generation Myval Octacor - Transcatheter Heart Valve (THV) in patients with severe, symptomatic, native aortic stenosis (AS).

METHODS

This multicenter, real-world observational registry included 123 patients with severe symptomatic AS, across 16 Indian centers who underwent treatment with the novel Myval Octacor THV. Study endpoints included all-cause mortality, all stroke, acute kidney injury (AKI), major vascular complications, moderate or severe paravalvular leakage (PVL) and new permanent pacemaker implantation (PPI) until 30 days follow-up.

RESULTS

Of the 123 patients (average age 70.07 ± 8.33 years), 37.4 % (n = 46) were female and 39.84 % presented with bicuspid valves. The technical success rate of the procedure was 100 % and the device success rate at 30 days was 98.4 %. At 30 days (n = 123) after the procedure, the overall mortality was 1.6 %. AKI occurred in 1.6 % of patients and there was no incidence of stroke, bleeding (types 3 and 4), and major vascular complications. In an analysis of 31 patients whose echocardiographic parameters were available across all timepoints, there were significant improvements in the mean pressure gradient (54.31 ± 18.19 mmHg vs. 10.42 ± 4.24 mmHg; p < 0.0001) and effective orifice area (0.66 ± 0.21 cm2 vs. 1.80 ± 0.44 cm2; p < 0.0001) from baseline to the 30-day follow-up. None of the patients experienced severe PVL, while moderate PVL was observed in two patients (1.6 %).

CONCLUSIONS

Early outcomes of the next-generation, novel Myval Octacor THV proved its safety and effectiveness in the treatment of severe AS.

Reinterventions After CoreValve/Evolut Transcatheter or Surgical Aortic Valve Replacement for Treatment of Severe Aortic Stenosis

BACKGROUND

Data on valve reintervention after transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) are limited.

OBJECTIVES

The authors compared the 5-year incidence of valve reintervention after self-expanding CoreValve/Evolut TAVR vs SAVR.

METHODS

Pooled data from CoreValve and Evolut R/PRO (Medtronic) randomized trials and single-arm studies encompassed 5,925 TAVR (4,478 CoreValve and 1,447 Evolut R/PRO) and 1,832 SAVR patients. Reinterventions were categorized by indication, timing, and treatment. The cumulative incidence of reintervention was compared between TAVR vs SAVR, Evolut vs CoreValve, and Evolut vs SAVR.

RESULTS

There were 99 reinterventions (80 TAVR and 19 SAVR). The cumulative incidence of reintervention through 5 years was higher with TAVR vs SAVR (2.2% vs 1.5%; P = 0.017), with differences observed early (≤1 year; adjusted subdistribution HR: 3.50; 95% CI: 1.53-8.02) but not from >1 to 5 years (adjusted subdistribution HR: 1.05; 95% CI: 0.48-2.28). The most common reason for reintervention was paravalvular regurgitation after TAVR and endocarditis after SAVR. Evolut had a significantly lower incidence of reintervention than CoreValve (0.9% vs 1.6%; P = 0.006) at 5 years with differences observed early (adjusted subdistribution HR: 0.30; 95% CI: 0.12-0.73) but not from >1 to 5 years (adjusted subdistribution HR: 0.61; 95% CI: 0.21-1.74). The 5-year incidence of reintervention was similar for Evolut vs SAVR (0.9% vs 1.5%; P = 0.41).

CONCLUSIONS

A low incidence of reintervention was observed for CoreValve/Evolut R/PRO and SAVR through 5 years. Reintervention occurred most often at ≤1 year for TAVR and >1 year for SAVR. Most early reinterventions were with the first-generation CoreValve and managed percutaneously. Reinterventions were more common following CoreValve TAVR compared with Evolut TAVR or SAVR.

Predictors, clinical impact, and management strategies for conduction abnormalities after transcatheter aortic valve replacement: an updated review

Transcatheter aortic valve replacement (TAVR) has increasingly become a safe, feasible, and widely accepted alternative surgical treatment for patients with severe symptomatic aortic stenosis. However, the incidence of conduction abnormalities associated with TAVR, including left bundle branch block (LBBB) and high-degree atrioventricular block (HAVB), remains high and is often correlated with risk factors such as the severity of valvular calcification, preexisting conditions in patients, and procedural factors. The existing research results on the impact of post-TAVR conduction abnormalities and permanent pacemaker (PPM) requirements on prognosis, including all-cause mortality and rehospitalization, remain contradictory, with varied management strategies for post-TAVR conduction system diseases across different institutions. This review integrates the latest research in the field, offering a comprehensive discussion of the mechanisms, risk factors, consequences, and management of post-TAVR conduction abnormalities. This study provides insights into optimizing patient prognosis and explores the potential of novel strategies, such as conduction system pacing, to minimize the risk of adverse clinical outcomes.

Transcatheter Aortic Valve Replacement: Current Status and Future Indications

In the past two decades, transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis and has become the standard of care regardless of surgical risk levels. Advances in transcatheter valve design across newer generations, improved imaging, greater operator expertise, and technical enhancements have collectively contributed to increased safety and a decline in procedural complications over this timeframe. The application of TAVR has progressively expanded to include younger patients with lower risks, who have longer life expectancies. This article offers an up-to-date review of the latest innovations in transcatheter delivery systems, devices, and its possible future indications.

Feasibility of Coronary Access Following Redo-TAVR for Evolut Failure: A Computed Tomography Simulation Study

BACKGROUND

Coronary accessibility following redo-transcatheter aortic valve replacement (redo-TAVR) is increasingly important, particularly in younger low-risk patients. This study aimed to predict coronary accessibility after simulated Sapien-3 balloon-expandable valve implantation within an Evolut supra-annular, self-expanding valve using pre-TAVR computed tomography (CT) imaging.

METHODS

A total of 219 pre-TAVR CT scans from the Evolut Low-Risk CT substudy were analyzed. Virtual Evolut and Sapien-3 valves were sized using CT-based diameters. Two initial Evolut implant depths were analyzed, 3 and 5 mm. Coronary accessibility was evaluated for 2 Sapien-3 in Evolut implant positions: Sapien-3 outflow at Evolut node 4 and Evolut node 5.

RESULTS

With a 3-mm initial Evolut implant depth, suitable coronary access was predicted in 84% of patients with the Sapien-3 outflow at Evolut node 4, and in 31% of cases with the Sapien-3 outflow at Evolut node 5 (P<0.001). Coronary accessibility improved with a 5-mm Evolut implant depth: 97% at node 4 and 65% at node 5 (P<0.001). When comparing 3- to 5-mm Evolut implant depth, sinus sequestration was the lowest with Sapien-3 outflow at Evolut node 4 (13% versus 2%; P<0.001), and the highest at Evolut node 5 (61% versus 32%; P<0.001).

CONCLUSIONS

Coronary accessibility after Sapien-3 in Evolut redo-TAVR relates to the initial Evolut implant depth, the Sapien-3 outflow position within the Evolut, and the native annular anatomy. This CT-based quantitative analysis may provide useful information to inform and refine individualized preprocedural CT planning of the initial TAVR and guide lifetime management for future coronary access after redo-TAVR.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02701283.