Challenges After the First Decade of Transcatheter Aortic Valve Replacement: Focus on Vascular Complications, Stroke, and Paravalvular Leak

Vascular management during transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR), as an alternative to open heart surgery, has been established as the standard therapy for patients with severe aortic valve stenosis. Vascular access management, the first step in a TAVR procedure, should be managed properly. Moreover, the transfemoral and alternatives such as the transaxillary/subclavian, transcarotid, transapical, and transcaval approaches are considered access routes during TAVR. More than 90% of cases can be treated via the transfemoral approach in the current TAVR era, whereas other approaches should be considered in patients in whom the transfemoral approach is not suitable. Vascular complications regardless of access route differences are a specific issue of TAVR caused by the use of large sheaths. With the increased number of TAVR cases, we must manage vascular complications and decrease the morbidity and mortality rates associated with TAVR procedures. Thus, this study aimed to review the vascular complications during TAVR and summarize their prognosis, prevention, and adequate management.

Vascular complications after transcatheter transfemoral aortic valve implantation: Modified sheath-to-femoral artery ratio as a new predictor

OBJECTIVE

Vascular complications (VCs) contribute to increased morbidity and mortality in patients who have undergone transcatheter aortic valve implantation (TAVI); however, studies on their incidence and predictors show conflicting results. In this study, we sought to assess the incidence, impact, and predictors of VCs in transfemoral (TF) TAVI and also investigated the predictive role of manufacturer's size charts and a new predictor modified sheath-to-femoral artery ratio.

METHODS

A total of 223 patients undergoing TF-TAVI were categorized into 2 groups. The patients were divided as eligible and ineligible according to the manufacturer's guidelines (MG), and the same patient cohort was dichotomized into eligible and ineligible on the basis of sheath-to-femoral artery ratio (SFAR) value of less than or greater than or equal to modified SFAR (md-SFAR). VCs (defined according to the Valve Academic Research Consortium II criteria) were retrospectively compared.

RESULTS

According to the manufacturer's size charts, 65 patients were unsuitable; however, 35 patients were ineligible for TF-TAVI per the md-SFAR criteria. Although VCs occurred in 42 (18.8%) patients, 17 (27.7%) of those patients were classified as ineligible according to MG, whereas 14 (41.2%) were classified as ineligible in the md-SFAR group. In a multiple logistic regression analysis that included md-SFAR, MG, SFAR ≥1.05, peripheral artery disease, and minimum iliofemoral artery diameter, only md-SFAR was the independent predictor of VCs (odds ratio=3.71, 95% confidence interval=1.13-12.53, p=0.031).

CONCLUSION

According to our results, md-SFAR might provide better patient selection to prevent VCs and improve outcomes in TF-TAVI procedures.

Prevalence of Posttranscatheter Aortic Valve Implantation Vascular Complications in Real Life

Background

Vascular complications (VCs) are commonly observed after transfemoral transcatheter aortic valve implantation (TAVI) procedures. Closure devices for the access site were developed to reduce their incidence. We aim to evaluate the prevalence, predictors, and outcomes of the occurrence of post-TAVI VCs.

Materials and Methods

A retrospective study was conducted on 1336 consecutive patients who underwent TAVI at the University Hospital of Toulouse, France, between January 2016 and March 2020. All included procedures were performed through the common femoral artery, and ProGlide^® was the used closure device. The studied population was divided into two groups depending on the occurrence of VCs defined according to Valve Academic Research Consortium-2 criteria.

Results

The mean age of the studied population was 84.4 ± 6.9, and 48% were male. 90% of TAVI interventions were performed through the right femoral artery. The prevalence of VCs was 18.8%, and 3.7% were major. Prolonged procedure duration was an independent predictor of VCs. Using the right access site and smaller introducer size (14 Fr) were preventive factors. No significant difference in mortality rate was detected between the two groups.

Conclusion

This study showed a low prevalence for post-TAVI VCs, especially for the major type. An increase in bleeding events and prolonged cardiac care unit stay were the common adverse outcomes.

Vascular Complications in TAVR: Incidence, Clinical Impact, and Management

Transcatheter aortic valve replacement (TAVR) has replaced surgical aortic valve replacement as the new gold standard in elderly patients with severe aortic valve stenosis. However, alongside this novel approach, new complications emerged that require swift diagnosis and adequate management. Vascular access marks the first step in a TAVR procedure. There are several possible access sites available for TAVR, including the transfemoral approach as well as transaxillary/subclavian, transcarotid, transapical, and transcaval. Most cases are primarily performed through a transfemoral approach, while other access routes are mainly conducted in patients not suitable for transfemoral TAVR. As vascular access is achieved primarily by large bore sheaths, vascular complications are one of the major concerns during TAVR. With rising numbers of TAVR being performed, the focus on prevention and successful management of vascular complications will be of paramount importance to lower morbidity and mortality of the procedures. Herein, we aimed to review the most common vascular complications associated with TAVR and summarize their diagnosis, management, and prevention of vascular complications in TAVR.

Three-dimensional transesophageal echocardiography is an attractive alternative to cardiac multi-detector computed tomography for aortic annular sizing: Systematic review and meta-analysis

BACKGROUND

Cardiac imaging is the cornerstone of the pretranscatheter aortic valve replacement (TAVR) assessment. Multi-detector computed tomography (MDCT) is considered the conventional imaging modality. However, there is still no definitive gold standard. Targeted cohort of inoperable high-risk patients with underlying comorbidities, particularly renal impairment, makes apparent the need for MDCT alternative. We aimed to demonstrate the correlation extent between MDCT and three-dimensional transesophageal echocardiography (3DTEE) aortic annular area measures and to answer the question: Is 3DTEE a good alternative to MDCT?

METHODS

A systematic literature search and meta-analysis were conducted to evaluate the degree of correlation and agreement between 3DTEE and MDCT aortic annular sizing. A thorough assessment of EMBASE, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. All studies comparing 3DTEE and MDCT in relation to aortic annular sizing were included.

RESULTS

Thirteen studies were included (N = 1228 patients). A strong linear correlation was found between 3DTEE and MDCT measurements of aortic annulus area (r = 0.84, P < 0.001), mean perimeter (r = 0. 0.85, P < 0.001), and mean diameter (r = 0.80, P < 0.001). Bland-Altman plots revealed smaller mean 3DTEE values in comparison to MDCT for aortic annular area, the mean difference being -2.22 mm² with 95% limits of agreement -12.79 to 8.36.

CONCLUSION

Aortic annulus measurements obtained by 3DTEE demonstrated a high level of correlation with those evaluated by MDCT. This makes 3DTEE a feasible choice for aortic annulus assessment, with advantage of real time assessment, lack of contrast, and no radiation exposure.

Intraventricular Vortex Interaction between Transmitral Flow and Paravalvular Leak

Paravalvular leak (PVL) is a complication of transcatheter aortic valve replacement. Despite its marked clinical impact, no previous study has reported how PVL affects the intraventricular fluid dynamics. This study aims to delineate vortex interaction between PVL and transmitral flow and the influence of PVL orifice location on intraventricular fluid dynamics using Echocardiographic Particle Image Velocimetry. Three different conditions of no PVL, anterior PVL and posterior PVL were experimentally studied and clinically compared. Circulation, impulse, kinetic energy (KE) and change in KE (ΔKE) were calculated. As well, vortex formation analyses and streamline description were performed to study vortex interactions. The anterior PVL jet streamed into the LV and interfered with the transmitral flow. Posterior PVL jet formed a large clockwise vortex and collided with transmitral flow, which resulted in flow disturbance. Compared to no PVL condition, average circulation, impulse, KE and ΔKE increased in presence of PVL. In conclusion, we found that PVL jets lead to abnormal vortex formation that interfere with natural advancement of transmitral flow, and negatively affect the LV fluid dynamics parameters. PVL orifice location strongly affects the intraventricular vortex formation, and posterior PVL may have more negative effects compared to anterior PVL.

Vascular complications associated with transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is now an accepted pathway for aortic valve replacement for patients who are at prohibitive, severe and intermediate risk for traditional aortic valve surgery. However, with this rising uptrend and adaptation of this new technology, vascular complications and their management remain an Achilles heel for percutaneous aortic valve replacement. The vascular complications are an independent predictor of mortality for patients undergoing TAVR. Early recognition of these complications and appropriate management is paramount. In this article, we review the most commonly encountered vascular complications associated with currently approved TAVR devices and their optimal percutaneous management techniques.

Assessment of Paravalvular Leak After Transcatheter Aortic Valve Replacement: Transesophageal Echocardiography Compared With Transthoracic Echocardiography

OBJECTIVES

Determine whether moderate or greater paravalvular leak (PVL) after transcatheter aortic valve replacement quantified using intraoperative transesophageal echocardiography (TEE) is associated with mortality and investigate the correlation between PVL grading using intraoperative TEE and postoperative transthoracic echocardiography (TTE).

DESIGN

Retrospective, observational study.

SETTING

Single academic institution.

PARTICIPANTS

The study comprised adult patients undergoing elective transcatheter aortic valve replacement between April 2011 and February 2014.

INTERVENTIONS

Patients were grouped by amount of PVL on intraoperative TEE into "significant" (moderate or greater) and "nonsignificant" (no, trivial, or mild) PVL groups. Demographics and patient characteristics were compared. Continuous variables were assessed with t-tests or Wilcoxon rank sum tests and categorical variables with the chi-square or Fisher exact test. A Cox proportional hazards model adjusted for EuroSCORE was used to test the independent association of PVL with late mortality, and covariate-adjusted survival curves were constructed. A Fleiss-Cohen-weighted kappa value was used to assess agreement between PVL grading using intraoperative TEE and postoperative TTE.

MEASUREMENTS AND MAIN RESULTS

One hundred ninety-six patients were grouped into the "significant" (n = 22) or "nonsignificant" (n = 174) PVL group. Twenty patients (10%) died during the follow-up period. Significant PVL on either TTE (p = 0.62, hazard ratio 1.68, 95% confidence interval [CI] 0.22-12.85) or TEE (p = 0.49, hazard ratio 0.49; 95% CI 0.06-3.68) was not associated with a survival difference. Modest agreement was found between PVL on intraoperative TEE and postoperative TTE (kappa = 0.47, CI 0.37-0.57, p < 0.0001).

CONCLUSIONS

Larger studies are needed to evaluate the association of PVL graded on intraoperative TEE with survival. There is modest agreement between the degree of PVL found on TEE and TTE.

Vascular complications post-transcatheter aortic valve procedures

Transcatheter aortic valve replacement (TAVR) has rapidly emerged as the standard of care for severe symptomatic aortic stenosis in patients whose comorbidities put them at prohibitive risk for surgical aortic valve replacement (SAVR). Several trials have demonstrated superior outcomes with TAVR compared to medical management alone. TAVR has also shown favorable outcomes in patients at high risk for SAVR. TAVR can be associated with significant vascular complications, which adversely impact outcomes, and operators should be cognizant of their early recognition and appropriate management. In this article, we review the major vascular complications associated with TAVR, along with optimal prevention and management strategies.

Transcatheter aortic valve replacement: focus on sex-related differences in outcomes

Transcatheter aortic valve replacement (TAVR) has transformed the management of severe aortic stenosis for high-risk and inoperable patients. The 10-year experience in Europe has proven the technology to be safe and effective in select populations. The PARTNER trial, the first prospective, randomized, controlled trial for TAVR, showed the technology to be superior to medical management for inoperable patients and equivalent to surgical aortic valve replacement for high-risk patients. Research in cardiovascular medicine has been dominated by studies on the male sex, due to the incidence of the disease process and partly due to historic predominance of male subjects in research studies. Alternatively, TAVR studies focused on high-risk and inoperable patients who are equally distributed by sex. Although sex-related differences are apparent in their baseline characteristics, outcomes have been mixed, with evidence suggesting that female patients may have a mortality advantage with TAVR. Herein we review the TAVR procedure and devices currently available and focus our discussion on outcomes after transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis.

New frontiers in aortic therapy: focus on current trials and devices in transcatheter aortic valve replacement

The first decade of clinical experience with transcatheter aortic valve replacement since 2002 saw the development of 2 main valve systems, namely the Edwards Sapien balloon-expandable valve series and the Medtronic self-expanding CoreValve. These 2 valve platforms now have achieved commercial approval and application worldwide in patients with severe aortic stenosis whose perioperative risk for surgical intervention is high or extreme. In the second decade of transcatheter aortic valve replacement, clinical experience and refinements in valve design have resulted in clinical drift towards lower patient risk cohorts. There are currently 2 major trials, PARTNER II and SURTAVI, that are both evaluating the role of transcatheter aortic valve replacement in intermediate-risk patient cohorts. The results from these landmark trials may usher in a new clinical paradigm for transcatheter aortic valve replacement in its second decade.

Stent Maps--Comparative Visualization for the Prediction of Adverse Events of Transcatheter Aortic Valve Implantations

Transcatheter aortic valve implantation (TAVI) is a minimally-invasive method for the treatment of aortic valve stenosis in patients with high surgical risk. Despite the success of TAVI, side effects such as paravalvular leakages can occur postoperatively. The goal of this project is to quantitatively analyze the co-occurrence of this complication and several potential risk factors such as stent shape after implantation, implantation height, amount and distribution of calcifications, and contact forces between stent and surrounding structure. In this paper, we present a two-dimensional visualization (stent maps), which allows (1) to comprehensively display all these aspects from CT data and mechanical simulation results and (2) to compare different datasets to identify patterns that are typical for adverse effects. The area of a stent map represents the surface area of the implanted stent - virtually straightened and uncoiled. Several properties of interest, like radial forces or stent compression, are displayed in this stent map in a heatmap-like fashion. Important anatomical landmarks and calcifications are plotted to show their spatial relation to the stent and possible correlations with the color-coded parameters. To provide comparability, the maps of different patient datasets are spatially adjusted according to a corresponding anatomical landmark. Also, stent maps summarizing the characteristics of different populations (e.g. with or without side effects) can be generated. Up to this point several interesting patterns have been observed with our technique, which remained hidden when examining the raw CT data or 3D visualizations of the same data. One example are obvious radial force maxima between the right and non-coronary valve leaflet occurring mainly in cases without leakages. These observations confirm the usefulness of our approach and give starting points for new hypotheses and further analyses. Because of its reduced dimensionality, the stent map data is an appropriate input for statistical group evaluation and machine learning methods.

Incidental moderate mitral regurgitation in patients undergoing coronary artery bypass grafting: update on guidelines and key randomized trials

Incidental moderate mitral regurgitation (MR) in patients presenting for coronary artery bypass grafting (CABG) is not only common but also probably adversely affects clinical outcome. The echocardiographic evaluation of incidental MR must be comprehensive and integrated, as it remains a cornerstone in management decisions. Current guidelines support surgical mitral intervention in this setting as a reasonable option, reflecting clinical equipoise towards moderate MR in the setting of planned CABG. There are currently 2 major randomized trials in progress that will test whether surgical correction of moderate MR combined with CABG improves major clinical outcomes as compared to CABG alone. These landmark trials will be completed in the near future. In the interim, significant progress in the fields of cardiac resynchronization therapy, transcatheter mitral valve intervention, and minimally invasive mitral valve surgery promise to affect the management alternatives for moderate MR in patients undergoing CABG regardless of operative risk. It is likely that in the coming decade there will be less tolerance for incidental moderate MR given its already known outcome effects and the multimodal interventions that continue to mature with better safety profiles.

The functional aortic annulus in the 3D era: focus on transcatheter aortic valve replacement for the perioperative echocardiographer

The functional aortic annulus represents a sound clinical framework for understanding the components of the aortic root complex. Recent three-dimensional imaging analysis has demonstrated that the aortic annulus frequently is elliptical rather than circular. Comprehensive three-dimensional quantification of this aortic annular geometry by transesophageal echocardiography and/or multidetector computed tomography is essential to guide precise prosthesis sizing in transcatheter aortic valve replacement to minimize paravalvular leak for optimal clinical outcome. Furthermore, three-dimensional transesophageal echocardiography accurately can quantify additional parameters of the functional aortic annulus such as coronary height for complete sizing profiles for all valve types in transcatheter aortic valve replacement. Although it is maturing rapidly as a clinical imaging modality, its role in transcatheter aortic valve replacement is seen best as complementary to multidetector computed tomography in a multidisciplinary heart team model.

Incidental moderate mitral regurgitation in patients undergoing aortic valve replacement for aortic stenosis: review of guidelines and current evidence

Recent evidence has shown that moderate mitral regurgitation is common and clinically relevant in patients presenting for surgical and transcatheter aortic valve replacement for aortic stenosis. Prospective multicenter clinical trials are now indicated to resolve the clinical equipoise about whether or not mitral valve intervention also is indicated at the time of aortic valve intervention. Advances in three-dimensional transesophageal echocardiography, transcatheter mitral interventions, and surgical aortic valve replacement, including the advent of sutureless valves, likely will expand the therapeutic possibilities for moderate mitral regurgitation in the setting of aortic valve interventions for severe aortic stenosis.