Long term outcomes of patients with aortic structural valve deterioration treated with transcatheter valve in valve implantation

Introduction

The Valve-in-Valve (ViV) technique is an established alternative for the treatment of structural bioprosthetic valve deterioration (SVD). Data describing the long term follow up of patients treated with this approach is scarce. We report on our long-term follow up outcomes of patients with SVD in the Aortic position treated with ViV.

Methods

Included were patients with symptomatic SVD in the aortic position valve who were treated by Valve in valve transcatheter aortic valve implantation (ViV-TAVI) during the years 20102019 in our center. Three main outcomes were examined during follow up: NYHA functional class, hemodynamic of the VIV-TAVI per echocardiography, and overall mortality.

Results

Our cohort consisted of 84 patients (mean age 78.8±8.9 years). The indications for aortic ViV were: SVD isolated aortic stenosis in 37.6%, SVD isolated aortic regurgitation in 42.2% and combined valve pathology in 20.0%. Self-expandable and balloon-expandable devices were used in 73 (85.9%) and 12 (14.1%), respectively. Average time of follow up was 3.74±2.4 years. 95% and 91% of patients were in NYHA functional class I/II at 1 and 5 year follow up respectively. At one year the mean trans-aortic valve pressure was 15.3±9.3 and rates of ≥ moderate aortic regurgitation were 3.7%. Survival was 91.4% (95% CI 85.6–97.7) at one year and 79.5% (95% CI 70.2–90.0) at 3 years.

Conclusion

ViV in the aortic position offers an effective and durable treatment option for patient with SVD, with low rates of all-cause mortality, excellent hemodynamic and improved functional capacity at 3 years follow up.

Funding Acknowledgement

Type of funding sources: None. NYHA functional class over follow up

Biodegradable polymer drug eluting stents versus durable polymer drug eluting stents for percutaneous coronary intervention

Background

Invasive angiography with subsequent revascularization is a widely used treatment method in patients with coronary heart disease. Although biodegradable polymer drug eluting stents (BP-DES) have been used for almost a decade now, clinical trials regarding their long-term outcomes are both sparse and inconsistent. We aimed to compare the long-term outcomes of patients undergoing percutaneous coronary intervention (PCI) with BP-DES versus durable polymer drug eluting stents (DP-DES).

Methods

Among 11,517 PCIs with second generation drug eluting stents preformed in our institution between 2007 and 2019, we identified 8042 procedures performed using DP-DES and 3475 using BP-DES. The primary outcome was the composite of all-cause mortality, recurrent myocardial infarction (re-MI), target vessel revascularization (TVR) and coronary artery bypass grafting (CABG). Propensity score matching was used to create a well-balanced cohort.

Results

Mean follow up was 4.8 years. Of the 3,413 matched pairs, 21% were females, and the mean age was 66. At one year, the primary outcome occurred in 9.6% patients versus 8.3% (p=0.05), and TVR rate was 4.1% versus 3% (p=0.005) in patients with DP-DES and BP-DES respectively. Within 5 years, the primary outcome occurred in in 24.9% versus 24.8% (p=0.83), and the rate of TVR was 9.8% versus 9.1% (p=0.07) in patients with DP-DES and BP-DES respectively.

Conclusions

Similar rates of the composite outcome were observed throughout the entire follow-up. TVR rates were lower in the DP-DES group at 1-year but equalized within 5 years.

Funding Acknowledgement

Type of funding sources: None.

Procedural and clinical outcomes of type 0 versus type 1 bicuspid aortic valve stenosis treated with transcatheter valve replacement: insights from the BEAT international collaborative registry

Background

Transcatheter aortic valve replacement (TAVR) is an established therapy for symptomatic severe aortic stenosis. Bicuspid aortic valves (BAV) were generally excluded from randomized trials due to anatomic features that may challenge TAVR (valve morphology, annulus geometry and size and severe calcifications). Nevertheless real-world registries have shown that a consistent number of BAV has been treated with TAVR. Whether BAV phenotype may affect acute or long-term outcomes following TAVR still remains unclear.

Purpose

Evaluate the impact of BAV phenotype on procedural and clinical outcomes after TAVR with new generation valves.

Methods

Patients included in the BEAT (Balloon vs Self-Expandable valve for the treatment of bicuspid Aortic valve sTenosis) registry were classified according to the BAV phenotype. Procedural and clinical outcomes of type 0 (2 cusps, 1 commissure, no raphe) vs type 1 (1 raphe) BAV are here reported. Primary endpoint was post-procedural device success, according to Valve Academic Research Consortium–2 (VARC-2) criteria. Secondary endpoints included procedural complications, rate of permanent pacemaker (PM) implantation and assessment of clinical outcomes at 30-day and 1-year follow-up.

Results

BAV 0 phenotype was present in 25 (7.1%) cases, and BAV 1 in 218 (61.8%). 3 (0.9%) patients with BAV 2 phenotype and 105 (29.8%) patients in whom BAV phenotype was undeterminable were excluded. Baseline characteristics of the two populations were well balanced. Mean STS score tended to be lower in type 0 vs type 1 BAV (3.35% ±1.8 vs 4.5% ± 3.0, p=0.062). Mean transvalvular gradient, aortic valve area (AVA), and left ventricular ejection fraction didn't differ between groups. According to CT findings moderate-severe aortic valve calcifications were less frequently present in type 0 vs type 1 (52% vs 71.1%, p=0.01). TAVR was performed under conscious sedation in most patients (89.7%), no differences were noted in terms of valve type, valve size, pre and postdilation between groups. There was no significant difference in any peri-procedural complication including pericardial tamponade, second valve implantation, valve embolization, annular rupture, aortic dissection, coronary occlusion, conversion to open surgery, and need of PM between groups however VARC-2 success tended to be lower in type 0 BAV versus type 1 (72% vs 86.7%; p=0.07). A higher rate of mean transvalvular gradient>20 mmHg was observed in the type 0 vs type 1 groups (respectively 24% vs 6%, p=0.007), while no differences were reported in the rate of moderate-severe aortic regurgitation. At 30-day and 1-year follow-up we did not find differences in clinical outcomes.

Conclusions

Our study confirms the feasibility of TAVR in both type 0 and type 1 BAV, however despite a lower rate of moderate-severe calcifications, a trend toward a lower VARC device success and a higher rate of mean transvalvular gradient >20 mmHg was observed in type 0 vs type 1 BAV.

Funding Acknowledgement

Type of funding source: None