Early detection of transcatheter heart valve dysfunction

Incidence, Outcomes and Predictors of Aortic Regurgitation After Transcatheter Aortic Valve Replacement in Al Azhar University Hospitals and National Heart Institute, Egypt

Background: Aortic regurgitation (AR), which has ill-defined predictors and an unknown long-term influence on outcomes, is a significant transcatheter aortic valve replacement (TAVR) constraint. Objective: this research aimed to assess the prevalence, identify predictors, and evaluate the outcomes of aortic regurgitation following trans catheter aortic valve implantation (TAVI). 1. To calculate the prevalence of aortic regurgitation in elderly patients receiving trans catheter aortic valve implantation who have severe symptomatic aortic stenosis. 2. To determine aortic regurgitation risk factors after trans catheter aortic valve implantation. Methods: From November 2017 to November 2020, this prospective observational study was done in the National Heart Institute on severe aortic valve stenosis patients above 65 years who were candidates for aortic valve replacement from the outpatient department. Results: LVEF significantly improved. Compared to before TAVI (55.08 ± 9.71), LVEF elevated to 58.9 ± 8.8 (P<0.001). Twenty-five patients (83.3%) showed class III/IV, four patients (13.3%) showed class II, and one patient (3.3%) showed class I before TAVI. While after TAVI, three patients (10%) only showed NYHA class III/IV, six patients (20 %) in class II, and 21 patients (70%) improved to be in class I. The left ventricular mass index mean was 158 ±32.37 before TAVI and 133.50 ±21.96 after TAVI (p<0.001). Compared to before TAVI (0.75 ± 0.2), mean aortic valve area was improved to 2.0 ± 0.2 following TAVI (P<0.001). A significant reduction in the mean pressure gradient from 47 ± 11.08 mmHg across the native valve prior to TAVI to 10.28 ± 3.21 mmHg across the prosthetic valve following TAVI (P <0.001). Expert commentary: The clinical and results of TAVR devices were clearly outlined in literature study. The study showed a high incidence of pacemaker implantation with Core valve and aortic regurgitation. This information strongly supports the need for a randomized trial with sufficient power to compare the most recent self-expandable valve generation to balloon expandable valves. In the 2019 PARTNER 3 prospective randomized trial, it was discovered that, when compared to surgical management, low-risk patients (defined as STS 4%) had a lower risk of the composite outcome of stroke, death, and rehospitalization at 1 year. Additionally, it was shown that TAVR had a lower risk of stroke and required less time in the hospital (3 days as opposed to 7, P0.001) than surgery [1]. In addition, despite an elevated permanent pacemaker implantation rate, the 2019 Medtronic Evolut Transcatheter Aortic Valve Replacement revealed no inferiority for composite all-cause stroke and death, as well as a statistically significant decrease in the rates of life-threatening bleeding, acute kidney injury and atrial fibrillation, compared with SAVR at 30 days following the procedure [2]. Conclusion: According to the study in high-risk patients with severe symptomatic aortic stenosis, TAVI is alternative, viable, safe, and successful therapy compared to traditional open-heart surgery.

Repeated transcatheter aortic valve implantation for the treatment of a degenerated transcatheter aortic valve implantation valve (valve-in-valve technique): a case report

Background

Valve-in-valve transcatheter aortic valve implantation (TAVI) has emerged as a competent alternative for the treatment of degenerated bioprosthetic valves after surgical aortic valve replacement, or during TAVI procedure as a bailout option. Herein, we report a rare case of a self-expandable Medtronic Evolut R valve into a failing Medtronic CoreValve, with the use of modern pre-TAVI imaging screening, suggesting the proper procedural design steps for so complicated implantations.

Case summary

A frail 78-year-old woman with a degenerated Medtronic Core Valve 26 mm bioprosthesis, implanted in 2011 due to severe aortic stenosis, was referred to our hospital due to worsening dyspnoea New York Heart Association III. The screening echocardiography documented severe aortic stenosis, while the classical risk scores were in favour of repeated TAVI (EuroSCORE II 5.67%). Computed tomography measurements and three-dimensional (3D) printing model were of great help for the proper valve selection (Medtronic Evolut R 26 mm), while the use of cerebral protection device (Claret Sentinel) was considered as a necessary part of the procedure. The simultaneous use of fluoroscopy and transoesophageal echocardiogram led to optimal haemodynamic result, confirmed by the discharge echocardiogram, with a significant clinical improvement during the first month follow-up.

Discussion

The main periprocedural concerns remain valve malpositioning, coronary artery obstruction, and high remaining transvalvular gradients. The multimodality pre-TAVI imaging screening may be helpful for precise procedural design. Despite the limited use of 3D models, it is necessary to adopt such tissue-mimicking phantoms to increase the possibility of optimal procedural result.