Effects of Bioprosthetic Valve Fracturing on Valve-in-Valve Transcatheter Aortic Valve Implantation Transvalvular Gradients.
Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is quickly becoming a routine and effective means by which to treat degenerated bioprosthetic valves. A known complication of ViV-TAVI is patient-prosthesis mismatch, which substantially affects survival. Bioprosthetic valve fracture is a method by which to reduce the risk of patient-prosthesis mismatch and post-ViV-TAVI transvalvular gradients. This study sought to determine the safety and efficacy of post-ViV-TAVI bioprosthetic valve fracture.
Patients with a history of surgical aortic valve replacement undergoing ViV-TAVI bioprosthetic valve fracture (N = 25) at the corresponding institution from 2015 to 2022 were cataloged for a retrospective analysis. The implanted transcatheter valves were Medtronic Evolut R, Evolut PRO, and Evolut PRO+. Gradients were assessed before and after implantation and after fracturing using transthoracic echocardiogram.
The mean left ventricular ejection fraction of patients who underwent fracturing was 55.04%. The average (SD) peak and mean (SD) transvalvular gradients before the intervention were 68.17 (19.09) mm Hg and 38.98 (14.37) mm Hg, respectively. After ViV-TAVI, the same gradients were reduced to 27.25 (12.27) mm Hg and 15.63 (6.47) mm Hg, respectively. After bioprosthetic valve fracture, the gradients further decreased to 17.59 (7.93) mm Hg and 8.860 (3.334) mm Hg, respectively. The average reduction in peak gradient associated with fracturing was 12.07 mm Hg (95% CI, 5.73-18.41 mm Hg; P = .001). The average reduction in mean gradient associated with valve fracturing was 6.97 mm Hg (95% CI, 3.99-9.74 mm Hg; P < .001).
Bioprosthetic valve fracture is a viable option for reducing residual transvalvular gradients after ViV-TAVI and should be considered in patients with elevated gradients (>20 mm Hg) or with concern for patient-prosthesis mismatch in patients who have an unacceptable risk for a redo sternotomy and surgical aortic valve replacement.
Hallak O
，Fischer K
，Ailawadi S
，Valencia D
，Yatsynovich Y
，Nazir R
，Schwartz B
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Transcatheter Aortic Valve Replacement in Low Surgical Risk Patients: An Updated Metanalysis of Extended Follow-Up Randomized Controlled Trials.
The long-term safety and effectiveness of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) in low surgical risk has not been evaluated in a pooled analysis. An electronic database search was conducted for randomized controlled trials with a maximal 5 years clinical and echocardiographic follow-up including low surgical risk patients who underwent TAVR or SAVR. We calculated odds ratio (OR) and 95% confidence intervals (CIs) using a random-effects model. Subgroups analysis was performed for permanent pacemaker implantation and paravalvular leaks. Three randomized controlled trials were included with a total of 2,611 low surgical risk patients (Society of Thoracic Surgeons score <4%). Compared with SAVR, the TAVR group had similar rates of all-cause mortality (OR 0.94,95% CI 0.65 to 1.37, p = 0.75) and disabling stroke (OR 0.84, 95% CI 0.52 to 1.36, p = 0.48). No significant differences were registered in the TAVR group in terms of major cardiovascular events (OR 0.96, 95% CI 0.67 to 1.38, p = 0.83), myocardial infarction (OR 0.69, 95% CI 0.34 to 1.40, p = 0.31), valve thrombosis (OR 3.11, 95% CI 0.29 to 33.47, p = 0.35), endocarditis (OR 0.71,95% CI 0.35 to 1.48, p = 0.36), aortic valve reintervention (OR 0.93, 95% CI 0.52 to 1.66, p = 0.80), and rehospitalization (OR 0.80, 95% CI 0.52 to 1.02, p = 0.07) compared with SAVR. However, TAVR patients had a higher risk of paravalvular leaks (OR 8.21, 95% CI 4.18 to 16.14, p <0.00001), but lower rates of new-onset atrial fibrillation (OR 0.27,95% CI 0.17 to 0.30, p <0.0001). The rates of permanent pacemaker implantation were comparable from 1 year up to a maximum of 5 years (OR 1.32, 95% CI 0.88 to 1.97, p = 0.18). Lastly, TAVR had a greater effective orifice area (0.10 cm2/m2, 95% CI 0.05 to 0.15, p = 0.0001), but similar transvalvular mean gradients (0.60, 95% CI 3.94 to 2.73, p = 0.72). In conclusion, TAVR patients had similar long-term outcomes compared with SAVR, except for an elevated risk of paravalvular leaks in the TAVR group and increased rates of atrial fibrillation in the SAVR cohort.
Di Pietro G
，Improta R
，De Filippo O
，Bruno F
，Birtolo LI
，Tocci M
，Fabris T
，Saade W
，Colantonio R
，Celli P
，Sardella G
，Esposito G
，Tarantini G
，Mancone M
，D'Ascenzo F
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