Impact of Paravalvular Leak on Outcomes After Transcatheter Aortic Valve Implantation: Meta-Analysis of Kaplan-Meier-derived Individual Patient Data

Sá, Michel Pompeu Barros de Oliveira; Jacquemyn, Xander; Eynde, Jef Van den; Tasoudis, Panagiotis; Erten, Ozgun; Sicouri, Serge; Macedo, Francisco; Pasala, Tilak; Kaple, Ryan; Weymann, Alexander; Ruhparwar, Arjang; Clavel, Marie‐Annick; Ramlawi, Basel

doi:10.1016/j.shj.2022.100118

Cited by 33 publications

(17 citation statements)

References 29 publications

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“…More recently, Jones et al 3 retrospectively reviewed 237 patients undergoing transfemoral TAVR using a balloon‐expanding valve and found a significantly increased mortality risk for each half‐grade of AI compared to no AI (HR 2.26 per 1 + AI, 95% CI 1.48–3.43, p < 0.001). Similarly, in a 2022 meta‐analysis using reconstructed Kaplan–Meier patient data by Sá et al, 17 mild paravalvular leak (PVL) was associated with significantly higher risk of mortality (23,287 patients; HR 1.35 95% CI 1.27–1.44 p < 0.001), cardiovascular mortality (10,982 patients; HR 1.27, 95% CI 1.1–1.48, p < 0.001), and rehospitalization (4564 patients; HR 1.64, 95% CI 1.39–1.94, p < 0.001) compared to no/trace PVL at subgroup analysis. Both of these analyses, however, were only limited to only patients with paravalvular AR 18 .…”

Section: Discussionmentioning

confidence: 89%

Mild aortic insufficiency following transcatheter aortic valve replacement: A systematic review and meta‐analysis

Hameed

Ahmed

Kumar

et al. 2023

Cathet Cardio Intervent

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Background Post‐procedural aortic insufficiency (AI) continues to be prevalent following transcatheter aortic valve replacement (TAVR). While several studies have assessed the outcomes of moderate‐severe AI following TAVR, the incidence, predictors, and outcomes of mild AI remain unclear. Methods A systematic literature review was performed to identify studies reporting on mild AI following TAVR. The primary outcome was pooled incidence of post‐TAVR mild AI. Secondary outcomes included pooled incidence of mild AI at 30 days and long term. The pooled incidence of midterm mortality in patients with post‐TAVR mild AI was also evaluated. The random effect generalized linear mixed‐effects model with logit‐transformed proportions and Hartung–Knapp adjustment was used to calculate pooled incidence rates. Meta‐regression was performed to identify predictors of mild AI. Results The pooled analysis included 19,241 patients undergoing TAVR across 50 studies. The mean age of patients ranged from 73 to 85 years, and female patients ranged from 20.0% to 83.3%. The overall pooled incidence of post‐TAVR mild AI was 56.1% (95% confidence interval [CI] 0.31–0.64). The pooled incidence of mild AI at 30 days was 33.7% (95% CI 0.12–0.37). At mean follow‐up of 1.15 years, the pooled incidence of mild AI was 37.0% (95% CI 0.16–0.45). The overall pooled incidence of Midterm mortality (mean follow‐up 1.22 years) in patients with mild AI was 14.8% (95% CI 0.10–0.25). At meta‐regression, none of the explored variables correlated with a difference in mild AI incidence. Conclusions In published studies to date, 50% of patients undergoing TAVR develop mild AI postoperatively. In 37% of patients, this persists in long term. Though the incidence of AI is likely improving with newer generation TAVR valves, the prevalence and outcomes of mild AI should be closely monitored as TAVR volume and indications expand to younger patients with long life expectancy. The long‐term outcomes of mild AI remain unclear. Further dedicated studies on post‐TAVR mild AI are needed.

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Section: Discussionmentioning

confidence: 89%

Mild aortic insufficiency following transcatheter aortic valve replacement: A systematic review and meta‐analysis

Hameed

Ahmed

Kumar

et al. 2023

Cathet Cardio Intervent

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“…On the one hand, higher deployments are associated with lower rates of conduction abnormalities and PPI 25,26 . On the other hand, these advantages carry the potential risk of valve dislocation (pop‐out) and PVL 25,26 and it is well known that PVL is associated with higher rates of mortality after TAVI over time 27 . An implantation depth of 3–5 mm has been suggested for the Evolut SEV to achieve better outcomes 26 .…”

Section: Discussionmentioning

confidence: 99%

“…25,26 On the other hand, these advantages carry the potential risk of valve dislocation (pop-out) and PVL 25,26 and it is well known that PVL is associated with higher rates of mortality after TAVI over time. 27 An implantation depth of 3-5 mm has been suggested for the Evolut SEV to achieve better outcomes. 26 Implantation depth (Figure 6) is defined as the average distance from the native aortic annulus plane (on the side of the noncoronary or right cusp and on the side of the left coronary cusp), to the most proximal edge of the implanted SEV (deepest level in the left ventricle).…”

Section: Summary Of Evidencementioning

confidence: 99%

Cusp‐overlap versus coplanar view in transcatheter aortic valve implantation with self‐expandable valves: A meta‐analysis of comparative studies

Sá

Eynde

Jacquemyn

et al. 2023

Cathet Cardio Intervent

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Background Permanent pacemaker implantation (PPI) is a common complication after transcatheter aortic valve implantation (TAVI). The cusp‐overlap view (COV) was adopted to reduce PPI risk after TAVI with self‐expandable valves (SEVs); however, the evidence remains scarce. We performed a systematic review with meta‐analysis comparing COV and the standard coplanar view (CPV) technique to evaluate their effectiveness and safety. Methods Following the PRISMA statement, data were extracted from studies published by August 2022 and found in PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, http://ClinicalTrials.gov, SciELO, LILACS, and Google Scholar. The primary outcome of interest was post‐procedural PPI and the secondary outcomes were new left bundle branch block (LBBB), moderate/severe paravalvular leak (PVL), valve dislocation (pop‐out); need of second transcatheter heart valve, 30‐day mortality, stroke, conversion to surgery, coronary obstruction, implantation depth (mm), and post‐TAVI mean gradients (mmHg). Results Eleven studies met our eligibility criteria and included 1464 patients in the COV group and 1743 patients in the CPV group. Patients who underwent TAVI with COV had lower risk of PPI (odds ratio 0.48; 95% confidence interval [CI] 0.33–0.70; p = 0.001) and higher implantation depths with COV (mean difference −0.83; 95% CI −1.2 to −0.45; p < 0.001). We did not observe any statistically significant differences in the rates of new LBBB, moderate/severe PVL, valve dislocation, need of second transcatheter heart valve, 30‐day mortality, stroke, conversion to surgery, coronary obstruction, and post‐TAVI mean gradients (mmHg). Conclusion In TAVI with SEVs, the application of COV is associated with lower risk of PPI compared with the standard CPV without increasing risk for adverse outcomes.

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“…Given this evidence, the incidence of significant PVL has been significantly reduced due to the development of prosthetic valve technology. However, recent reports have suggested that even mild PVL could be a determinant of worse midterm and long‐term outcomes following TAVI 80–82 . It is noteworthy that newer generation valves with a taller skirt could seal the bioprosthesis and reduce the severity of PVL 83 .…”

Section: Complications Associated With Heart Failure Hospitalization ...mentioning

confidence: 99%

“…However, recent reports have suggested that even mild PVL could be a determinant of worse midterm and long-term outcomes following TAVI. [80][81][82] It is noteworthy that newer generation valves with a taller skirt could seal the bioprosthesis and reduce the severity of PVL. 83 Moreover, a recent report by Akodad et al demonstrated that late dilatation (a median of 4.6 months) for symptomatic transcatheter heart valve dysfunction reduced the transvalvular gradient and the PVL to less than or equal to mild in all cases with greater than mild PVL without inducing any complications.…”

Section: Paravalvular Leakagementioning

confidence: 99%

Determinants and treatments of heart failure after transcatheter aortic valve implantation: moving up a notch

et al. 2023

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Transcatheter aortic valve implantation (TAVI) has become an alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis in elderly and comorbid population. Significant improvement in heart function has been observed in patients undergoing TAVI, but numerous patients are readmitted to hospital for heart failure (HF). Moreover, repeat HF hospitalization is strongly associated with an adverse prognosis and increases the financial burden of health care. Although studies have identified pre-existing and post-procedural factors that contribute to HF hospitalization after TAVI, there is a paucity of data regarding optimal post-procedural pharmacological treatments. This review aims to provide an overview of the current understanding of mechanisms, determinants, and potential treatments of HF following TAVI. We first review the pathophysiology of left ventricular (LV) remodelling, coronary microcirculation disorder, and endothelial dysfunction in patients with aortic stenosis and then examine the impact of TAVI on these conditions. We then present evidence of various factors and complications that may interplay with LV remodelling and contribute to HF events after TAVI. Next, we describe the triggers and predictors of early and late HF rehospitalizations following TAVI. Lastly, we discuss the potential of conventional pharmacological treatments, including renin-angiotensin blockers, beta-blockers, and diuretics in TAVI patients. The paper explores the potential of newer drugs, including sodium-glucose co-transporter 2 inhibitors, anti-inflammatory drugs, and ion supplementation. Comprehensive knowledge in this field may aid in recognizing successful existing therapies, developing effective new treatments, and establishing dedicated patient care strategies during follow-up after TAVI.

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Impact of Paravalvular Leak on Outcomes After Transcatheter Aortic Valve Implantation: Meta-Analysis of Kaplan-Meier-derived Individual Patient Data

Cited by 33 publications

References 29 publications

Mild aortic insufficiency following transcatheter aortic valve replacement: A systematic review and meta‐analysis

Mild aortic insufficiency following transcatheter aortic valve replacement: A systematic review and meta‐analysis

Cusp‐overlap versus coplanar view in transcatheter aortic valve implantation with self‐expandable valves: A meta‐analysis of comparative studies

Determinants and treatments of heart failure after transcatheter aortic valve implantation: moving up a notch

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