A versatile transapical device for aortic valvular disease: One-year outcomes of a multicenter study on the J-Valve system

Simultaneous transapical transcatheter aortic and mitral valve replacement in patients with severe valve dysfunction: initial experience

BACKGROUND

Simultaneous transcatheter mitral valve in valve (VIV) replacement and aortic valve replacement experience is limited. We report our initial experience with simultaneous transapical transcatheter aortic and mitral valve replacement in patients with severe valve dysfunction.

METHODS

A total of 8 patients had simultaneous transcatheter heart valve implants for severe mitral bioprosthesis failure (VIV), with a second valve procedure that included native aortic regurgitation (n = 3) or degenerated bioprostheses in the aortic position (n = 5). All patients were treated with a self-expandable J-valve transcatheter valve, using the transapical approach.

RESULTS

The mean age of the patients was 73.1 ± 6.2 years. The mean Society of Thoracic Surgeons score was 13.8 ± 6.3%. Device success was 100% according to Valve Academic Research Consortium-2 criteria. No other procedure-associated complications occurred, including left ventricular outflow tract obstruction and valve migration. The mean hospital lengths of stay after the procedure were 11.5 ± 8.0 days. No deaths occurred at 30 days. At a median follow-up period of 28.7 ± 22.3 months, no patients died. All patients were in New York Heart Association functional classes I-II. Echocardiographic parameters at follow-up showed a normofunctioning J valve in the mitral position and a mean max mitral flow velocity of 2.0 ± 0.5 m/s; the J valve in the aortic position was also normofunctioning, and the mean max aortic flow velocity was 2.3 ± 0.5 m/s.

CONCLUSION

Simultaneous transapical transcatheter aortic and mitral valve replacement using the self-expandable J valve appears to be a feasible and effective alternative to redo surgery.

Aortic valve disorders and left ventricular assist devices

Aortic valve disorders are important considerations in advanced heart failure patients being evaluated for left ventricular assist devices (LVAD) and those on LVAD support. Aortic insufficiency (AI) can be present prior to LVAD implantation or develop de novo during LVAD support. It is usually a progressive disorder and can lead to impaired LVAD effectiveness and heart failure symptoms. Severe AI is associated with worsening hemodynamics, increased hospitalizations, and decreased survival in LVAD patients. Diagnosis is made with echocardiographic, device assessment, and/or catheterization studies. Standard echocardiographic criteria for AI are insufficient for accurate diagnosis of AI severity. Management of pre-existing AI includes aortic repair or replacement at the time of LVAD implant. Management of de novo AI on LVAD support is challenging with increased risks of repeat surgical intervention, and percutaneous techniques including transcatheter aortic valve replacement are assuming greater importance. In this manuscript, we provide a comprehensive approach to contemporary diagnosis and management of aortic valve disorders in the setting of LVAD therapy.

Die Aortenklappeninsuffizienz – können wir mit interventionellen Therapieoptionen mehr Patienten helfen?

Die hochgradige, symptomatische Aortenklappeninsuffizienz ist häufig nicht einfach zu diagnostizieren und bei einem relevanten Anteil der Patienten noch nicht ausreichend gut behandelt. Dabei können auch Patienten mit höherem operativen Risiko von einem Aortenklappenersatz profitieren. Durch das Fortschreiten der interventionellen Therapieoptionen stellt die Transkatheter-Aortenklappenimplantation (TAVI) mittlerweile eine ebenfalls zu berücksichtigende Therapieoption dar. Dadurch kann es möglich werden, auch ältere und kränkere Patienten einer adäquaten und notwendigen Therapie der Aortenklappeninsuffizienz zuzuführen.

Emergently Alteration of Procedural Strategy During Transcatheter Aortic Valve Replacement to Prevent Coronary Occlusion: A Case Report

Background

Coronary occlusion is an uncommon but fatal complication of transcatheter aortic valve replacement (TAVR) with a poor prognosis.

Case Presentation

A patient with symptomatic severe bicuspid aortic valve stenosis was admitted to a high-volume center specializing in transfemoral TAVR with self-expanding valves. No anatomical risk factors of coronary occlusion were identified on pre-procedural computed tomography analysis. The patient was scheduled for a transfemoral TAVR with a self-expanding valve. Balloon pre-dilatation prior to prosthesis implantation was routinely used for assessing the supra-annular structure and assessing the risk of coronary occlusion. Immediately after the tubular balloon inflation, fluoroscopy revealed that the right coronary artery was not visible, and the flow in the left coronary artery was reduced. The patient would be at high-risk of coronary occlusion if a long stent self-expanding valve was implanted. Therefore, our heart team decided to suspend the ongoing procedure. A transapical TAVR with a 23 mm J-valve was performed 3 days later. The prosthesis was deployed at a proper position without blocking the coronary ostia and the final fluoroscopy showed normal flow in bilateral coronary arteries with the same filling as preoperatively.

Discussion

Our successful case highlights the importance of a comprehensive assessment of coronary risk and a thorough understanding of the TAVR procedure for the heart team. A short-stent prosthesis is feasible for patients at high risk of coronary occlusion. Most importantly TAVR should be called off even if the catheter has been introduced when an extremely high risk of coronary obstruction is identified during the procedure and no solution can be found.

Transcatheter Aortic Valve Implantation for Severe Pure Aortic Regurgitation with Dedicated Devices

Aortic regurgitation (AR) is not the most common valvular disease; however, its prevalence increases with age, with more than 2% of those aged >70 years having at least moderate AR. Once symptoms related to AR develop, the prognosis becomes poor. Transcatheter aortic valve implantation for patients with pure severe AR and at prohibitive surgical risk is occasionally performed, but remains a clinical challenge due to absence of valvular calcium, large aortic root and increased stroke volume. These issues make the positioning and deployment of transcatheter aortic valve implantation devices unpredictable, with a tendency to prosthesis embolisation or malposition. To date, the only two dedicated transcatheter valves for AR are the J-Valve (JC Medical) and the JenaValve (JenaValve Technology). Both devices have been used successfully via the transapical approach. The transfemoral experience is limited to first-in-human publications and to a clinical trial dedicated to AR, for which the completion date is still pending.

Transcatheter Tricuspid Valve-in-Valve Replacement Using a J-Valve System for a Failed Tricuspid Bioprosthesis

Background

Redo operation for failed tricuspid bioprosthetic valves is associated with high morbidity and mortality. Transcatheter tricuspid valve-in-valve implantation has become an acceptable option for high-risk patients with a failed tricuspid bioprosthesis. We present a case of successful tricuspid valve-in-valve implantation using a J-valve in a failed tricuspid bioprosthesis position. Case Summary. A 48-year-old male, who had a failed tricuspid bioprosthesis, presented with right-side heart failure, right-to-left shunting at the atrial level, severe dyspnea, cyanosis, peripheral edema, hepatauxe, and ascites. After the interdisciplinary assessment, we successfully performed transcatheter tricuspid valve-in-valve implantation with the J-valve system. At 34-month postoperative follow-up, the patient had no symptoms of heart failure and the echocardiogram showed good valve position and well hemodynamic status.

Conclusions

This case demonstrated that the J-valve system may be a new option for high-risk patients with a failed tricuspid bioprosthetic valve.

Transcatheter aortic valve replacement for aortic regurgitation in Asians: TAVR for aortic regurgitation in Asians

AIMS

Although surgical aortic valve replacement (SAVR) is currently the recommended intervention for patients with native AR without aortic stenosis, a significant proportion of Asian patients undergo transcatheter aortic valve replacement (TAVR), which has not been studied fully for safety and outcomes. This systematic review aims to examine the characteristics and outcomes of Asian patients with pure native aortic regurgitation (AR) undergoing TAVR.

METHODS AND RESULTS

PubMed, Embase, Scopus, Web of Science and Cochrane CENTRAL were systematically searched for randomised controlled trials, observational studies and case reports published  from inception to 2 April 2020, involving patients of Asian ethnicity with pure native aortic regurgitation who had undergone TAVR. Our primary outcome was all-cause mortality, with secondary outcomes including all major complications. Five studies (n=274 patients) and eight case reports were included. Device success was reported in 94.9% of the patients, the all-cause mortality rate was 4.4%, 2.5% were converted to SAVR, 1.7% had post-operative paravalvular leak and 6.7% required permanent pacemaker implantation.

CONCLUSIONS

TAVR has demonstrated acceptable safety and efficacy in Asian patients with pure AR displaying low mortality rates and few adverse outcomes.

Short- and Long-Term Outcome after Emergent Cardiac Surgery during Transcatheter Aortic Valve Implantation

Objective: Our study aimed to evaluate short- and long-term outcomes of patients who required emergent conversion from transcatheter aortic valve implantation (TAVI) to open surgery. Besides, the reasons and procedural settings of emergent cardiac surgery (ECS) were also reported.

Methods: We retrospectively reviewed the patients who underwent TAVI in our institution between 2012 and 2019 and collected the clinical data of cases who converted from TAVI to bail-out surgery. Telephone and outpatient follow-ups were performed.

Results: Of 516 TAVI patients, 20 required ECS, and the bail-out surgery occurred less frequently with the increase in TAVI volume. The most common reason for conversion was left ventricular perforation (7/20, 35.0%). Thirty-day mortality was 35.0% in ECS patients. Kaplan–Meier survival curves showed that the cumulative survival rate was 65.0% at 1 year, 50.1% at 5 years in all ECS patients, and 77.1% at 5 years in patients who survived over 30 days after conversion.

Conclusion: Although the bail-out operation was performed immediately after TAVI abortion, ECS still associated with high 30-day mortality. The long-term survival benefit was seen in patients surviving from bail-out surgery. An experienced TAVI team is of crucial importance in avoiding ECS-related life-threatening complications and providing effective salvage surgery.

Comparison of Procedural and 1-Year Clinical Results of Transcatheter Aortic Valve Implantation Using Prostheses with Different Design of Support Frame

Our study aimed to investigate whether the frame design of transcatheter heart valve (THV) affects the procedural and clinical results of transcatheter aortic valve implantation (TAVI).We retrospectively reviewed 163 patients with aortic stenosis who underwent TAVI using different types of THV (Edwards SAPIEN, n = 31; Venus-A, n = 63; and J-Valve, n = 69). The procedural outcomes and follow-up results for 1-year were compared among groups.The patients who underwent TAVI using J-Valve had a higher mean transaortic pressure gradient than those using SAPIEN or Venus-A after TAVI (1-year follow-up; P = 0.017, P < 0.001, respectively), whereas no difference was observed between the patients with SAPIEN and Venus-A prosthesis (P = 0.150). The incidence of permanent pacemaker implantation was highest in patients with Venus-A (19.0%), followed by SAPIEN (9.7%), and lowest in J-Valve (4.3%) (P = 0.025). No difference was observed in the 30-day mortality rate among the groups (P = 1.000). Moreover, Kaplan-Meier survival analysis revealed that there was no significant difference in the 1-year cumulative patient survival rate among three patient cohorts (log-rank, P = 0.850).The frame design of THVs could affect the valve-related hemodynamics and the incidence of permanent pacemaker implantation in TAVI, whereas it did not influence the survival rate of TAVI patients during 1-year follow-up period. All three THVs provided a convincing short-term outcome for TAVI patients.

Structural Valve Deterioration after Transcatheter Aortic Valve Implantation Using J-Valve: A Long-Term Follow-Up

Purpose: Our study aimed to investigate the structural valve deterioration (SVD) after transcatheter aortic valve implantation (TAVI) using J-Valve.

Methods: In all, 14 patients with aortic stenosis (AS) and 4 patients with pure aortic regurgitation (PAR) were available in the study. Four-year follow-up was performed in all patients, and the clinical data and echocardiographic findings were recorded and analyzed.

Results: All patients survived at the 4-year follow-up. There was no evidence of morphological SVD or prosthetic valve thrombosis in enrolled patients. None of the hemodynamic SVD occurred in patients with PAR. Mean gradients decreased from 61.93 ± 15.42 mm Hg (pre-TAVI) to 19.64 ± 9.16 mm Hg (discharge) in patients with AS (p <0.001); subsequently, a slight increase was observed in the mean trans-aortic gradient throughout follow-up (p = 0.967). Overall, in patients with AS, six individuals suffered moderate (3/14, 21.4%) or severe (3/14, 21.4%) hemodynamic SVD at 4-year follow-up.

Conclusions: The limited number of cases provides a preliminary indication of the long-term efficacy of TAVI using J-Valve in patients with PAR. In patients with AS, although the higher rate of SVD was observed, the overall transcatheter heart valve (THV) hemodynamics remained stable over time after prosthetic valve implantation and the long-term durability of J-Valve was convincing.