Real-World Outcomes for the Fifth-Generation Balloon Expandable Transcatheter Heart Valve in the United States

Transcatheter Aortic Valve Replacement With Intra-Annular Self-Expanding or Balloon-Expandable Valves: The Multicenter International NAVULTRA Registry

BACKGROUND

No comparative data exist with the self-expanding Navitor (NAV) and the balloon-expandable SAPIEN 3 Ultra (ULTRA) transcatheter heart valves (THVs).

OBJECTIVES

This study sought to investigate the 1-year outcomes of transcatheter aortic valve replacement using the intra-annular NAV and the ULTRA THVs.

METHODS

The NAVULTRA (Navitor and SAPIEN 3 Ultra) registry included consecutive patients who underwent transfemoral transcatheter aortic valve replacement at 16 centers with NAV or ULTRA between November 2018 and April 2024. Propensity score matching was used for adjustment. The primary outcomes of interest were all-cause death and the composite of all-cause death, disabling stroke, and hospitalization for heart failure at 1 year.

RESULTS

The overall study cohort included 3,878 patients treated with NAV (n = 1,746) or ULTRA (n = 2,176). The propensity score-matched population resulted in 1,363 pairs. At 1 year, the rate of death from any cause was 9.7% with NAV and 9.9% with ULTRA (adjusted P = 0.585). Similarly, there were no significant differences in primary composite outcome (13.6% in the NAV group and 12.6% in the ULTRA group; adjusted P = 0.218). The rate of new permanent pacemaker implantation (20.6% vs 10.6%; adjusted P < 0.01) and heart failure rehospitalization (4.6% vs 2.8%; adjusted P < 0.05) was higher in NAV group. At 1 year, the use of NAV was associated with higher rates of mild paravalvular leak (OR: 1.53; 95% CI: 1.01 to 2.33; adjusted P < 0.05) but lower mean transprosthetic gradients compared with ULTRA (mean change:-3.90, 95% CI: -4.47 to -3.34; adjusted P < 0.01).

CONCLUSIONS

Both intra-annular THVs were associated with similar 1-year clinical outcomes; however, differences were observed in secondary clinical endpoints and valve hemodynamic performance.

Paravalvular Leak After Transcatheter Aortic Valve Implantation: Results From 3600 Patients

BACKGROUND

Paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) is associated with poor outcomes. Mild PVL remains prevalent after TAVI, and its impact on long-term survival is unclear. This study aimed to examine the incidence, impact on survival, and progression of PVL.

METHODS

This was a retrospective, single-institution cohort study of TAVIs between November 2012 and January 2023. Patients were stratified by 30-day PVL severity: none to trace, mild, and moderate to severe. Multivariable logistic regression was performed to identify risk factors associated with increasing PVL severity. Kaplan-Meier survival estimation and Cox proportional hazards regression were performed.

RESULTS

A total of 3600 patients underwent TAVI. Of these, 2719 (75.5%) had none to trace PVL, 808 (22.5%) had mild PVL, and 73 (2.0%) had moderate to severe PVL at 30 days. On multivariable logistic regression, later years of valve implantation (2017-2023) were protective against PVL progression. Kaplan-Meier estimates of the 3 groups were significantly different (P < .001) with the moderate to severe group having reduced survival. On Cox regression, moderate to severe PVL was associated with increased mortality (hazard ratio, 1.80; 95% Cl, 1.31-2.46; P < .001), whereas mild PVL was not (hazard ratio, 1.01; 95% CI, 0.89-1.15; P = .88) compared with none to trace PVL. For Kaplan-Meier estimates comparing the none to trace and mild PVL groups alone, landmark analysis showed reduced survival in the mild PVL group after 2 years (P = .03); however, this late reduction in survival in the mild PVL group did not persist on multivariable analysis (P = .14).

CONCLUSIONS

After TAVI, moderate to severe PVL is associated with reduced survival compared with none to trace PVL. Mild PVL may result in a delayed survival reduction.

Rationale and Design of the CREATE Trial: A Multicenter, Randomized Comparison of Continuation or Cessation of Single Antithrombotic Therapy at 1 Year After Transcatheter Aortic Valve Replacement

BACKGROUND

Current guidelines and expert consensus recommend lifelong single antiplatelet therapy for patients undergoing transcatheter aortic valve replacement who have no indication for anticoagulation or dual antiplatelet therapy. However, there is no direct evidence from randomized controlled trials supporting this practice. Furthermore, the optimal duration of antiplatelet therapy in this population has not been adequately investigated.

METHODS AND RESULTS

CREATE (A Multicenter Randomized Controlled Study to Evaluate Cessation of Antithrombotic Therapy at 1 Year in TAVR Patients-The CREATE Study) is a prospective, multicenter, open-label, randomized controlled trial for patients who have undergone successful transcatheter aortic valve replacement and have no indication for long-term oral anticoagulation or antiplatelet therapy. Eligible patients are free from major bleeding and ischemic events for 1 year postprocedure before being randomized 1:1 to single antiplatelet therapy (control group) or no antiplatelet therapy (experimental group). The primary efficacy end point is the incidence of bleeding events, defined by the VARC-3 (Valve Academic Research Consortium-3) criteria, at 1-year postrandomization. The primary safety end point is a composite of cardiac death, myocardial infarction, and ischemic stroke at 1 year. The trial is powered for both superiority in efficiency and noninferiority in safety. Accordingly, a total of 3380 patients will be enrolled.

CONCLUSIONS

The CREATE trial aims to assess if stopping antiplatelet therapy at 1-year after transcatheter aortic valve replacement reduces bleeding risk without increasing ischemic events in patients not requiring chronic antithrombotic therapy.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2400087454.

Glimpse Into the Hemodynamic Performance of Myval Series vs Sapien 3 Ultra Resilia

•The Myval series are novel balloon-expandable transcatheter heart valves.•The postprocedural effective orifice area and mean pressure gradient of the Myval series were compared with those of the Sapien 3 Ultra Resilia using published data.•The Myval series seems to have effective orifice areas and mean pressure gradients comparable to those of Sapien 3 Ultra Resilia.

Long-Term Bioprosthetic Valve Durability After Transcatheter Aortic Valve Replacement With Supra-Annular Self-Expanding Versus Intra-Annular Balloon-Expandable Valves in Patients With a Small Aortic Annulus

BACKGROUND

The long-term valve durability of supra-annular self-expanding valves (SEV) and intra-annular balloon-expandable valves (BEV) in patients with small aortic annuli remains unexplored.

AIMS

This study aimed to determine the long-term bioprosthetic valve durability with SEV versus BEV in patients with small aortic annuli.

METHODS

This retrospective study included patients with severe aortic stenosis (AS) and an aortic annulus area of 430 mm2 or less who underwent transcatheter aortic valve replacement using SEV and BEV between October 2009 and December 2022. Based on the Valve Academic Research Consortium's three definitions, the endpoints were hemodynamic structural valve deterioration (SVD) and bioprosthetic valve failure (BVF). Inverse probability of treatment weighting (IPTW) was used to compare between the two groups and adjust for baseline characteristics. The Fine-Gray subdistribution hazard model accounted for the competing risk of death.

RESULTS

In total, 565 patients (204 treated with SEV and 361 treated with BEV) were included. The median follow-up duration was 3.6 years [2.0 years, 5.7 years], and the maximum was 12.3 years. Hemodynamic SVD and BVF were less frequently identified in the SEV group than in the BEV group (1.1% vs. 9.1% within 5 years, 0.7% vs. 8.1% within 5 years, respectively). On the IPTW adjusted Fine-Gray subdistribution hazard model analysis, hemodynamic SVD was less frequent in SEV compared with BEV (Hazard Ratio [HR]: 0.16; 95% Confidence Interval [CI]: 0.04-0.56, p = 0.004). SEV was also associated with a lower BVF risk than BEV (HR: 0.25; 95% CI: 0.08-0.76, p = 0.015).

CONCLUSIONS

SEV appears to be more suitable for long-term valve durability in patients with a small aortic annulus.

1-Year Real-World Outcomes of TAVR With the Fifth-Generation Balloon-Expandable Valve in the United States

BACKGROUND

Longer term outcomes of transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 Ultra RESILIA (S3UR) valve over its predecessors have not been reported in a national registry.

OBJECTIVES

The aim of this study was to compare the 1-year clinical and echocardiographic outcomes of the S3UR with those of the SAPIEN 3 (S3) and SAPIEN 3 Ultra (S3U) in the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry.

METHODS

From September 2022 to March 2023, patients who underwent native TAVR with the S3UR or the S3 or S3U valve were propensity matched and compared. Predictors of 1-year outcomes were identified. The median follow-up time was 358 days (Q1-Q3: 47-365 days) for the S3UR and 364 days (Q1-Q3: 80-365 days) for the S3 and S3U.

RESULTS

A total of 4,598 S3UR patients were propensity matched with 4,598 and 32,536 S3 and S3U patients. At discharge, effective orifice areas were larger in the S3UR group (P < 0.0001). The lower discharge mean gradient in the S3UR group was maintained at 30 days and 1 year (P < 0.0001 for all). At 1 year, all-cause mortality (7.6% vs 9.7%; HR: 0.8; 95% CI: 0.67-0.93; P = 0.004), mild or greater paravalvular leak (PVL) (15.6% vs 18.5%; HR: 0.82; 95% CI: 0.69-0.97; P = 0.02), and life-threatening bleeding (2.0% vs 2.7%; HR: 0.7; 95% CI: 0.54-0.94; P = 0.03) were lower in the S3UR group. S3UR and mild or greater PVL were predictive of 1-year mortality in the overall cohort and in low-risk patients. Valve reintervention remained rare at 1 year (0.6% vs 0.4%; HR: 1.46; 95% CI: 0.77-2.78; P = 0.25).

CONCLUSIONS

TAVR with the S3UR is associated with superior 1-year clinical outcomes and lower gradients than its predecessors, with less PVL and low valve reintervention. Longer follow-up will determine the durability of the RESILIA technology in the SAPIEN valve platform.

Transcatheter Aortic Valve Replacement Beyond Severe Aortic Stenosis: JACC State-of-the-Art Review

Transcatheter aortic valve replacement (TAVR) has become the preferred treatment option in appropriate patients with symptomatic severe aortic stenosis (AS). A number of advancements have since expanded the eligible population to bicuspid aortic valve with feasible anatomy; small aortic annuli; low-flow, low-gradient AS; and younger patients. Focus has also shifted beyond the symptomatic severe patients to asymptomatic severe and moderate AS, as early valve replacement may prevent irreversible cardiac remodeling. Dedicated devices to treat native aortic regurgitation have shown encouraging short-term outcomes. While the expansion of TAVR to younger patients has raised questions about valve durability and feasibility of reintervention, valve-in-valve TAVR has thus far shown encouraging midterm results. In this review, we summarize the evidence in these contemporary TAVR populations, exploring both the promise and challenge of broadening the patient pool for this minimally invasive procedure.

Prosthesis-Patient Mismatch: Current State of Evidence

PURPOSE OF REVIEW

Prosthesis-patient mismatch (PPM) remains a significant concern in valve intervention. This review highlights the current evidence surrounding PPM, compares its impact after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI), and addresses ongoing debates in the literature regarding valve selection, procedural strategies, and future approaches to improve patient outcomes.

RECENT FINDINGS

Recent evidence highlights that moderate to severe PPM is associated with increased mortality and adverse cardiac events, particularly in younger, active patients and those with smaller aortic annuli. Studies have emphasized the role of optimized prosthesis sizing, advanced imaging modalities, and next-generation valve technologies in mitigating PPM. Additionally, TAVI appears to outperform surgical approaches in reducing severe PPM, particularly in high-risk populations. Despite significant progress, PPM remains a persistent challenge in valve intervention procedures, particularly among patients with smaller aortic annuli and those at risk for suboptimal hemodynamic performance. Addressing this issue requires continued innovation in prosthesis design, including valves with improved hemodynamic profiles and more sizing options. Long-term research is essential to better understand the clinical impact of PPM, evaluate valve durability across various types, and develop strategies to prevent its occurrence.

Transcatheter Aortic Valve Replacement in Bicuspid Aortic Valve Disease: A Review of the Existing Literature

Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure used to replace a damaged aortic valve with a prosthetic valve. TAVR has exceeded surgical aortic valve replacement (SAVR) due to shorter procedures and recovery times. Though initially approved for patients with aortic stenosis at a high surgical risk, TAVR's indications have now broadened to include high, intermediate, and low-risk patients. This review focuses on the evolving role of TAVR in patients with bicuspid aortic valves (BAV). We examine the anatomical and hemodynamic differences between tricuspid aortic valve and BAV, highlighting the unique challenges TAVR faces in BAV patients.

Valve Performance Between Latest-Generation Balloon-Expandable and Self-Expandable Transcatheter Heart Valves in a Small Aortic Annulus

BACKGROUND

Transcatheter aortic valve replacement (TAVR) using a self-expandable valve (SEV) promotes better hemodynamics compared with a balloon-expandable valve (BEV) in a small aortic annulus (SAA).

OBJECTIVES

The authors sought to compare hemodynamic properties and clinical outcomes between the latest-generation BEV and SEV after TAVR for SAA.

METHODS

We retrospectively analyzed 1,227 patients undergoing TAVR for aortic stenosis with SAA, defined as an annulus area ≤430 mm2, using the BEV (SAPIEN3 Ultra RESILIA, Edwards Lifesciences) and SEV (Evolut FX, Medtronic). The impact of valve design on severe prosthesis-patient mismatch, aortic valve mean pressure gradient ≥20 mm Hg, paravalvular leakage (PVL) ≥ mild, new permanent pacemaker implantation (PMI), and modified VARC-3 device success at discharge was evaluated using logistic regression and propensity score analysis.

RESULTS

Of 1,227 patients, 798 (65.0%) underwent TAVR with BEV implantation. TAVR using BEV had a relatively higher rate of severe prosthesis-patient mismatch (OR: 1.74; 95% CI: 0.54-5.62) and significantly higher incidence of mean pressure gradient ≥20 mm Hg (OR: 2.05; 95% CI: 0.91-4.62) than that using SEV. By contrast, the BEV showed significantly lower incidence of PVL ≥ mild (OR: 0.19; 95% CI: 0.14-0.26), and new PMI (OR: 0.53; 95% CI: 0.33-0.86). The rate of device success was comparable between the BEV and the SEV. These results were confirmed by propensity score analysis.

CONCLUSIONS

In TAVR for SAA, SEV demonstrated better hemodynamics than the latest BEV, whereas the latest BEV had lower incidences of PVL ≥ mild and new PMI than the SEV.

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.