Impact of paravalvular regurgitation on the mid-term outcome after transcatheter and surgical aortic valve replacement

Abstract

OBJECTIVES The aim of this study was to evaluate the incidence and prognostic impact of paravalvular regurgitation (PVR) on the outcome after transcatheter (TAVR) and surgical aortic valve replacement (SAVR) for aortic stenosis. METHODS The nationwide FinnValve registry included data on 6463 consecutive patients who underwent TAVR (n = 2130) or SAVR (n = 4333) with a bioprosthesis for the treatment of aortic stenosis during 2008–2017. The impact of PVR at discharge after TAVR and SAVR on 4-year mortality was herein investigated. RESULTS The rate of mild PVR was 21.7% after TAVR and 5.2% after SAVR. The rate of moderate-to-severe PVR was 3.7% after TAVR and 0.7% after SAVR. After TAVR, 4-year survival was 69.0% in patients with none-to-trace PVR, 54.2% with mild PVR [adjusted hazard ratio (HR) 1.64, 95% confidence interval (CI) 1.35–1.99] and 48.9% with moderate-to-severe PVR (adjusted HR 1.61, 95% CI 1.10–2.35). Freedom from PVR-related reinterventions was 100% for none-to-mild PVR and 95.2% for moderate-to-severe PVR. After SAVR, mild PVR (4-year survival 78.9%; adjusted HR 1.29, 95% CI 0.93–1.78) and moderate-to-severe PVR (4-year survival 67.8%; adjusted HR 1.36, 95% CI 0.72–2.58) were associated with worse 4-year survival compared to none-to-trace PVR (4-year survival 83.7%), but the difference did not reach statistical significance in multivariable analysis. Freedom from PVR-related reinterventions was 99.5% for none-to-trace PVR patients, 97.9% for mild PVR patients and 77.0% for moderate-to-severe PVR patients. CONCLUSIONS This multicentre study showed that both mild and moderate-to-severe PVR were independent predictors of worse survival after TAVR. Mild and moderate-to-severe PVR are not frequent after SAVR, but tend to decrease survival also in these patients. Clinical trial registration number ClinicalTrials.gov Identifier: NCT03385915.

Minimizing Paravalvular Regurgitation With the Novel SAPIEN 3 Ultra TAVR Prosthesis: A Real-World Comparison Study

“…Moderate or severe PVR after TAVR has been consistently shown to increase mid-and long-term mortality (6-8, 21, 23). Several reports have also suggested a worse outcome for even mild PVR (7)(8)(9)22). Numerous factors have been identified to favor the risk for PVR.…”

Editorial comment: “Plug‐In Hybrid”—Are we ready for this in heart valve surgery?

“…3 Mild PVL has been considered harmless until the advent of transcatheter aortic valve implantation generated large amounts of patients with mild PVL giving rise to concern regarding a potential long-term detrimental effect. 11 Inspecting the literature carefully reveals similar associations for PVL after classic surgery. 10 The occurrence of PVL after classic surgery have been associated with endocarditis (a factor, i.e., relatively independent of technical aspects) and a whole series of technical factors that may or may not be avoided during the index valve replacement.…”

Cardiac Surgery 2020 Reviewed

“…Finally, results from the GALILEO trial (comparison of rivaroxaban plus ASS versus dual antiplatelet therapy in TAVI) suggest that anticoagulation is able to reduce the incidence of prosthetic valve thrombosis, 40 but is associated with an increase in mortality. 41 Thus, the signals for better long-term survival with SAVR may be the result of a mix of different components, which may not represent a statistically significant disadvantage by themselves. Two additional publications addressed the role of TAVI as treatment for patients with degenerated aortic bioprostheses (valve-in-valve TAVI).…”