Impact of device landing zone calcification patterns on paravalvular regurgitation after transcatheter aortic valve replacement with different next-generation devices

Abstract

ObjectiveResidual paravalvular regurgitation (PVR) has been associated to adverse outcomes after transcatheter aortic valve replacement (TAVR). This study sought to evaluate the impact of device landing zone (DLZ) calcification on residual PVR after TAVR with different next-generation transcatheter heart valves.Methods642 patients underwent TAVR with a SAPIEN 3 (S3; n=292), ACURATE neo (NEO; n=166), Evolut R (ER; n=132) or Lotus (n=52). Extent, location and asymmetry of DLZ calcification were assessed from contrast-enhanced CT imaging and correlated to PVR at discharge.ResultsPVR was ≥moderate in 0.7% of S3 patients, 9.6% of NEO patients, 9.8% of ER patients and 0% of Lotus patients (p<0.001), and these differences remained after matching for total DLZ calcium volume. The amount of DLZ calcium was significantly related to the degree of PVR in patients treated with S3 (p=0.045), NEO (p=0.004) and ER (p<0.001), but not in Lotus patients (p=0.698). The incidence of PVR ≥moderate increased significantly over the tertiles of DLZ calcium volume (p=0.046). On multivariable analysis, calcification of the aortic valve cusps, LVOT calcification and the use of self-expanding transcatheter aortic valve implantation (TAVI) prostheses emerged as predictors of PVR.ConclusionsThe susceptibility to PVR depending on the amount of calcium was mainly observed in self-expanding TAVI prostheses. Thus, DLZ calcification is an important factor to be considered in prosthesis selection for each individual patient, keeping in mind the trade-off between PVR reduction, risk of new pacemaker implantation and unfavourable valve ha emodynamics.

Assessment of Paravalvular Leak Severity and Thrombogenic Potential in Transcatheter Bicuspid Aortic Valve Replacements Using Patient-Specific Computational Modeling

“…PVL is associated with serious complications including increased chances of requiring a second valve replacement, heart failure, hemolytic anemia, and increased mortality [11]. Various hemodynamic and structural parameters including aortic regurgitation index and device landing zone calcification are often used for assessing the risk of PVL and predict PVL severity [11,13]. However, due to anatomical complexity and uniqueness, the range of these clinical parameters may vary for BAV patients, limiting their applicability to assess the risk of post-procedural PVL accurately in BAV patients, and making it crucial to analyze the risk of PVL in each BAV patient, individually.…”

Comprehensive assessment of the aortic valve in critically ill patients for the non-cardiologist. Part II: Chronic aortic regurgitation of the native valve

“…However, AR commonly co-exists with aortic dilatation, necessitating evaluation of the thoracic aorta by thoracic CT. Most recent cardiac CT research in the field of AV disease focusses on the question whether specific anatomical features, such as bicuspid AV and calcification severity, predict outcome (mortality, iatrogenic AR, …) after TAVR [38][39][40][41]. take home message on the utility of Cmr in ar severity grading:…”

Smart materials in cardiovascular implants: Shape memory alloys and shape memory polymers

“…56 Moreover, this ability to conform to asymmetries in the annulus can actually distort the implanted valve leading to paravalvular leak and disrupted leaflet kinetics. [56][57][58] However, in heavily calcified landing zones, self-expanding valves may still be the valve of choice since balloon-expanding valves have an increased risk for annular rupture due to the potential of exerting more outward force on the annulus than the shape memory material. 59,60 In addition to the complication of paravalvular leak, transcatheter aortic valves frequently require pacemaker implantation, but have a decreased risk for stroke when compared to surgical aortic valve replacement.…”

“…Transcatheter valve delivery stents take advantage of the shape memory effect of SMAs allowing for self‐expansion with conformation to the calcifications and other asymmetries in the annulus securing the valve in place 56 . Moreover, this ability to conform to asymmetries in the annulus can actually distort the implanted valve leading to paravalvular leak and disrupted leaflet kinetics 56‐58 . However, in heavily calcified landing zones, self‐expanding valves may still be the valve of choice since balloon‐expanding valves have an increased risk for annular rupture due to the potential of exerting more outward force on the annulus than the shape memory material 59,60 …”