Comparison of third generation balloon-expandable Edwards Sapien 3 versus self-expandable Evolut R in transcatheter aortic valve implantation: a meta-analysis

Comparison of 1-year Follow-up Echocardiographic Outcomes of Sapien 3 Versus Evolut R Bioprosthetic Transcatheter Aortic Valves: A Single-center Retrospective Iranian Cohort Study

OBJECTIVE

The current study aimed to compare 1-year echocardiographic outcomes of the new generations of self-expanding (Evolut R) versus balloon-expandable (Sapien 3) bioprosthetic transcatheter aortic valves.

METHODS

In this study, gradients and flow velocities obtained from transthoracic Doppler-echocardiography were retrospectively collected from patients who underwent 2 new generations of transcatheter aortic valve implantation interventions with Sapien 3 and Evolut R valves. Patients underwent echocardiography before the procedure and at discharge, 6 months, and 1-year follow-up.

RESULTS

Of the 66 patients, 28 received Sapien 3 and 38 received Evolut R valves. Evolut R valve presented a lower mean gradient at all follow-up time points compared with Sapien 3 valves (14.4 mm Hg, 14.9 mm Hg, 15.5 mm Hg compared with 10.1 mm Hg, 11.6 mm Hg, 11.8 mm Hg, respectively; all P -values <0.001). Small valve sizes of Evolut R, including 23 and 26, had higher echocardiographic mean gradient or peak gradient at the time of discharge compared with larger valves, including sizes 29 and 34 (11.1 mm Hg and 11.2 mm Hg vs. 10.2 mm Hg, 9.1 mm Hg) and 1-year follow-up (11.0 mm Hg, 11.0 mm Hg vs. 9.9 mm Hg, 8.4 mm Hg; all P -values = 0.001). Although Sapien 3 valves demonstrated a higher peak gradient in smaller sizes at discharge (18.44 mm Hg in size 23 vs. 17.9 mm Hg, 16.5 mm Hg in size 26 and 29, respectively; P = 0.001), the peak gradients did not show a statistically significant difference in the 1-year follow-up.

CONCLUSIONS

The current study detected significantly lower mean and peak gradients in Evolut R compared with Sapien 3 at all follow-up time points. Furthermore, smaller valve sizes were associated with significantly higher gradients at all follow-ups, regardless of the valve type.

Meta-analysis of short- and long-term clinical outcomes of the self-expanding Evolut R/pro valve versus the balloon-expandable Sapien 3 valve for transcatheter aortic valve implantation

BACKGROUND

The Evolut R/Pro and the Sapien 3 are the most commonly valve systems used today for transcatheter aortic valve implantation (TAVI). However, there is a still uncertainty regarding the efficacy and safety comparison of these two valves.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing the Evolut R/Pro versus the Sapien 3. The primary outcome was all-cause mortality (short and long-term). The secondary outcomes were stroke, bleeding, permanent pacemaker implantation (PPI), acute kidney injury (AKI), major vascular complication, device success, moderate- severe aortic regurgitation (AR), and pressure gradients.

RESULTS

Twenty-one publications totaling 35,248 patients were included in the analysis. Evolut R/Pro was associated with higher risk of short-term all-cause mortality (OR = 1.31;95% CI 1.15-1.49, p < 0.001) and a trend of higher long-term mortality (OR = 1.07;95% CI 1.00-1.16, p = 0.06). The Evolut R/Pro was associated with higher risk of PPI and AR and lower risk for bleeding, major vascular complication, and pressure gradients. There was no significant difference between the groups regarding the risk of stroke, AKI and device success.

CONCLUSIONS

The Evolut R/Pro valve system compared to the Sapien 3 is associated with higher risk of short-term mortality, significant AR and PPI while providing the advantage of lower risk of bleeding, major vascular complication, and lower residual transvalvular gradients.

Early acute kidney injury after transcatheter aortic valve implantation: predictive value of currently available risk scores

BACKGROUND

Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is a frequent complication associated with adverse outcomes and mortality. Various scores have been developed to predict this complication in the coronary setting. However, none have ever been tested in a large TAVI population. This study aimed to evaluate the power of four different scores in predicting AKI after TAVI.

METHODS

Overall, 1535 consecutive TAVI patients from the observational multicentric "Magna Graecia" TAVI registry were included in the analysis. Of the study population, 235 (15.31%) developed AKI early. The Mehran, William Beaumont Hospital, CR₄EATME₃AD₃, and ACEF scores were calculated retrospectively.

RESULTS

The patients who developed TAVI-related AKI had significantly higher absolute values of all risk scores than those who did not. The receiver-operating characteristic analysis also showed a significant correlation between these four scores and AKI, but without a significant difference among all of them (p value = 0.176). Nevertheless, based on their area under the curve values (≤0.604 for all), none had adequate diagnostic accuracy in predicting TAVI-related AKI. Importantly, multivariate analysis identified myocardial revascularization close to the TAVI procedure and implantation of self-expanding prostheses, as well as atrial fibrillation, low-osmolar contrast media administration, corrected contrast medium volume, and any transfusion (p value < 0.05 for all) as independent risk factors for AKI.

CONCLUSIONS

Although high values of current AKI risk scores are significantly associated with the development of this complication, these are not sufficiently accurate. Further studies are needed so that a TAVI-dedicated AKI risk score may be created.

Insights in a restricted temporary pacemaker strategy in a lean transcatheter aortic valve implantation program

OBJECTIVES

To study the safety and feasibility of a restrictive temporary-RV-pacemaker use and to evaluate the need for temporary pacemaker insertion for failed left ventricular (LV) pacing ability (no ventricular capture) or occurrence of high-degree AV-blocks mandating continuous pacing.

BACKGROUND

Ventricular pacing remains an essential part of contemporary transcatheter aortic valve implantation (TAVI). A temporary-right-ventricle (RV)-pacemaker lead is the standard approach for transient pacing during TAVI but requires central venous access.

METHODS

An observational registry including 672 patients who underwent TAVI between June 2018 and December 2020. Patients received pacing on the wire when necessary, unless there was a high-anticipated risk for conduction disturbances post-TAVI, based on the baseline-ECG. The follow-up period was 30 days.

RESULTS

A temporary-RV-pacemaker lead (RVP-cohort) was inserted in 45 patients, pacing on the wire (LVP-cohort) in 488 patients, and no pacing (NoP-cohort) in 139 patients. A bailout temporary pacemaker was implanted in 14 patients (10.1%) in the NoP-cohort and in 24 patients (4.9%) in the LVP-cohort. One patient in the LVP-cohort needed an RV-pacemaker for incomplete ventricular capture. Procedure time was significantly longer in the RVP-cohort (68 min [IQR 52-88.] vs. 55 min [IQR 44-72] in NoP-cohort and 55 min [IQR 43-71] in the LVP-cohort [p < 0.005]). Procedural high-degree AV-block occurred most often in the RVP-cohort (45% vs. 14% in the LVP and 16% in the NoP-cohort [p ≤ 0.001]). Need for new PPI occurred in 47% in the RVP-cohort, versus 20% in the NoP-cohort and 11% in the LVP-cohort (p ≤ 0.001).

CONCLUSION

A restricted RV-pacemaker strategy is safe and shortens procedure time. The majority of TAVI-procedures do not require a temporary-RV-pacemaker.

Advancements in Transcatheter Aortic Valve Implantation: A Focused Update

Transcatheter aortic valve implantation (TAVI) has become the leading technique for aortic valve replacement in symptomatic patients with severe aortic stenosis with conventional surgical aortic valve replacement (SAVR) now limited to patients younger than 65-75 years due to a combination of unsuitable anatomies (calcified raphae in bicuspid valves, coexistent aneurysm of the ascending aorta) and concerns on the absence of long-term data on TAVI durability. This incredible rise is linked to technological evolutions combined with increased operator experience, which led to procedural refinements and, accordingly, to better outcomes. The article describes the main and newest technical improvements, allowing an extension of the indications (valve-in-valve procedures, intravascular lithotripsy for severely calcified iliac vessels), and a reduction of complications (stroke, pacemaker implantation, aortic regurgitation).