Pure aortic valve regurgitation: SAVR is the gold standard, but TAVR is another gun

Remote ischaemic preconditioning for transcatheter aortic valve replacement: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) has become an important treatment in patients with aortic valve disease with the continuous advancement of technology and the improvement of outcomes. However, TAVR-related complications still increase patient morbidity and mortality. Remote ischaemic preconditioning (RIPC) is a simple procedure that provides perioperative protection for many vital organs. However, the efficiency of RIPC on TAVR remains unclear based on inconsistent conclusions from different clinical studies. Therefore, we will perform a protocol for a systematic review and meta-analysis to identify the efficiency of RIPC on TAVR.

METHODS AND ANALYSIS

English databases (PubMed, Web of Science, Ovid Medline, Embase and Cochrane Library), Chinese electronic databases (Wanfang Database, VIP Database and China National Knowledge Infrastructure) and trial registry databases will be searched from inception to December 2023 to identify randomised controlled trials of RIPC on TAVR. We will calculate mean differences or standardised mean differences with 95% CIs for continuous data, and the risk ratio (RR) with 95% CIs for dichotomous data by Review Manager version 5.4. Fixed-effects model or random-effects model will be used according to the degree of statistical heterogeneity assessed by the I-square test. We will evaluate the risk of bias using the Cochrane risk-of-bias tool 2 and assess the evidence quality of each outcome by the Grading of Recommendations Assessment, Development and Evaluation. The robustness of outcomes will be evaluated by trial sequential analysis. In addition, we will evaluate the publication bias of outcomes by Funnel plots and Egger's regression test.

ETHICS AND DISSEMINATION

Ethical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42023462926.

Application of echocardiography in transcatheter aortic valve replacement in patients with severe aortic regurgitation and correlation analysis of postprocedural complications

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is gradually becoming an alternative therapy for patients who cannot adapt to surgical treatment or have contraindications.

OBJECTIVES

The purpose of this study was to investigate the value of echocardiography in the evaluation of severe AR patients treated with TAVR and to analyze the correlations with postprocedural complications to improve the evaluation and screening of patients.

METHODS

We retrospectively analyzed clinical and echocardiographic data of 70 patients with severe AR. Periaortic valve structures were carefully measured by esophageal echocardiography (TEE) and compared with the multilayer slice computed tomography (MSCT) findings. Real-time three-dimensional esophageal echocardiography (RT-3D TEE) was monitored during the operation, and a 30-day postprocedural follow-up was performed. The relationship between postprocedural complications and patients' clinical data or periaortic valve structures was analyzed by multifactorial analysis to identify relevant predictors of complications.

RESULTS

The TEE measurements of periaortic valve structures were in good agreement with the MSCT measurements. Among the patients who underwent successful operations, both left atrial (LA) and left ventricular (LV) diameters were reduced, and the left ventricular ejection fraction (LVEF) was improved 30 days after TAVR compared with the preprocedural period (P < .05). Permanent pacemakers were implanted in 15 patients. The presence of preprocedural right bundle branch block (RBBB) (OR: 2.93; 95% CI: 1.18-12.70; P = .01) was an independent factor for permanent pacemaker implantation after TAVR.

CONCLUSIONS

Echocardiography plays an extremely important role in TAVR procedures. The presence of preprocedural RBBB can be an independent predictor of postprocedural pacemaker implantation.

Trends and Outcomes of Transcatheter Aortic Valve Implantation in Aortic Insufficiency: A Nationwide Readmission Database Analysis

Transcatheter aortic valve implantation (TAVI) has increasingly been utilized in patients with aortic insufficiency (AI) with insufficient data on its safety. The Nationwide Readmissions Database (NRD) was queried to identify patients undergoing TAVI for AI. Net clinical events (composite of in-hospital mortality, stroke, major bleeding) and procedural complications were assessed using a propensity-score matched (PSM) analysis to calculate adjusted odds ratios (OR). A total of 185,703 (AI 3873, aortic stenosis [AS] 181,830) patients were included in the analysis. Due to a significant difference in the baseline characteristics, a matched sample of 7929 patients (AI 3873, AS 4056) was selected. At index admission, the adjusted odds of in-hospital NACE (aOR 2.0, 95% CI 1.59-2.51), mortality (aOR 3.06, 95% CI 2.38-5.47), major bleeding (aOR 1.53, 95% CI 1.13-2.06) and valvular complications (aOR 9.48, 95% CI 6.73-13.38) were significantly higher in patients undergoing TAVI for AI compared with those undergoing TAVI for AS. However, there was no significant difference in the incidence of NACE, mortality, stroke, major bleeding, and need for permanent pacemaker implantation at 30- and 180-days follow-up. TAVI in AI was associated with a higher risk of periprocedural NACE, mortality, and major bleeding. The risk of these complications attenuated at 30- and 180-day readmission.

Clinical outcomes of TAVI with the Myval balloon-expandable valve for non-calcified aortic regurgitation

BACKGROUND

Transcatheter aortic valve replacement (TAVR) in non-calcified aortic regurgitation (NCAR) is an off-label procedure. The balloon-expandable Myval includes extra-large sizes (30.5 mm and 32 mm) of interest in this setting.

AIMS

We aimed to evaluate the safety and feasibility of Myval in NCAR.

METHODS

This was an international, multicentre, observational study that enrolled all consecutive patients with symptomatic severe NCAR undergoing TAVR with the Myval device. The images were centrally analysed.

RESULTS

A total of 113 patients were recruited, 64.6% were men, the mean age was 78.4±7.5 years, and the Society of Thoracic Surgeons score was 2.7±1.7%. Aortic root dilatation was present in 59.3% of patients, 7.1% were bicuspid, and the mean annular area was 638.6±106.0 mm2. The annular area was beyond the recommended range for extra-large sizes in 2.6% of cases, and additional volume was added in 92% (median 4 cc, up to 9 cc). The extra-large sizes were used in 95 patients (84.1%), and the mean oversizing was 17.9±11.0%. The technical success rate was 94.7%; the rate of residual ≥moderate aortic regurgitation was 8.9%, and the pacemaker rate was 22.2%. There were no cases of annular rupture, cardiac tamponade, or aortic dissection, but in 4 patients (3.5%) valve embolisation occurred (1 antegrade and 3 ventricular), all in cases with a tapered left ventricle outflow tract (p=0.007). Thirty-day and 1-year mortality were 5.3% and 9.7%, respectively. Technical success was associated with better survival (97.1% vs 72.7%; p=0.012), and valve embolisation was the main determinant of mortality (p=0.047).

CONCLUSIONS

Myval is a feasible and safe option for selected non-operable patients with NCAR and demonstrated good midterm outcomes and lack of impact of oversizing on device durability.

The Technological Basis of a Balloon-Expandable TAVR System: Non-occlusive Deployment, Anchorage in the Absence of Calcification and Polymer Leaflets

Leaflet durability and costs restrict contemporary trans-catheter aortic valve replacement (TAVR) largely to elderly patients in affluent countries. TAVR that are easily deployable, avoid secondary procedures and are also suitable for younger patients and non-calcific aortic regurgitation (AR) would significantly expand their global reach. Recognizing the reduced need for post-implantation pacemakers in balloon-expandable (BE) TAVR and the recent advances with potentially superior leaflet materials, a trans-catheter BE-system was developed that allows tactile, non-occlusive deployment without rapid pacing, direct attachment of both bioprosthetic and polymer leaflets onto a shape-stabilized scallop and anchorage achieved by plastic deformation even in the absence of calcification. Three sizes were developed from nickel-cobalt-chromium MP35N alloy tubes: Small/23 mm, Medium/26 mm and Large/29 mm. Crimp-diameters of valves with both bioprosthetic (sandwich-crosslinked decellularized pericardium) and polymer leaflets (triblock polyurethane combining siloxane and carbonate segments) match those of modern clinically used BE TAVR. Balloon expansion favors the wing-structures of the stent thereby creating supra-annular anchors whose diameter exceeds the outer diameter at the waist level by a quarter. In the pulse duplicator, polymer and bioprosthetic TAVR showed equivalent fluid dynamics with excellent EOA, pressure gradients and regurgitation volumes. Post-deployment fatigue resistance surpassed ISO requirements. The radial force of the helical deployment balloon at different filling pressures resulted in a fully developed anchorage profile of the valves from two thirds of their maximum deployment diameter onwards. By combining a unique balloon-expandable TAVR system that also caters for non-calcific AR with polymer leaflets, a powerful, potentially disruptive technology for heart valve disease has been incorporated into a TAVR that addresses global needs. While fulfilling key prerequisites for expanding the scope of TAVR to the vast number of patients of low- to middle income countries living with rheumatic heart disease the system may eventually also bring hope to patients of high-income countries presently excluded from TAVR for being too young.