Impact of Valve Size on Prosthesis–Patient Mismatch and Aortic Valve Gradient After Transcatheter versus Surgical Aortic Valve Replacement

Aalaei‐Andabili, Seyed Hossein; Lee, Teng C.; Waheed, Nida; Bavry, Anthony A.; Petersen, John W.; Wayangankar, Siddharth A.; Arnaoutakis, George J.; Anderson, R. David

doi:10.1177/1556984519838706

Cited by 3 publications

(5 citation statements)

References 27 publications

(32 reference statements)

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“…Patient-prosthesis mismatch occurs when the effective orifice area (EOA) of the implanted prosthetic valve is too small for the patient's body size ( 21 ) and contributes to structural valve deterioration ( 22 , 23 ), associated with worse long-term survival ( 24 ). Aalaei-Andabili et al ( 25 ) found the incidence of PPM was almost double following SAVR compared to TAVR (54% vs. 29%, p < 0.001), especially among patients receiving a valve size ≤23 mm (SAVR, 65% vs. TAVR, 48%, p = 0.048). To avoid PPM in the initial SAVR operation, aortic annular/root enlargement can be performed; as evident in this study where more annular enlargement procedures were performed and the median valve size of implanted valves increased to 25 mm in the post-TAVR era.…”

Section: Discussionmentioning

confidence: 98%

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Trends in surgical aortic valve replacement in pre- and post-transcatheter aortic valve replacement eras at a structural heart center

Norton

Ward

Tully

et al. 2023

Front. Cardiovasc. Med.

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BackgroundThe advent of transcatheter aortic valve replacement (TAVR) has directly impacted the lifelong management of patients with aortic valve disease. The U.S. Food and Drug Administration has approved TAVR for all surgical risk: prohibitive (2011), high (2012), intermediate (2016), and low (2019). Since then, TAVR volumes are increasing and surgical aortic valve replacements (SAVR) are decreasing. This study sought to evaluate trends in isolated SAVR in the pre- and post-TAVR eras.MethodsFrom January 2000 to June 2020, 3,861 isolated SAVRs were performed at a single academic quaternary care institution which participated in the early trials of TAVR beginning in 2007. A formal structural heart center was established in 2012 when TAVR became commercially available. Patients were divided into the pre-TAVR era (2000–2011, n = 2,426) and post-TAVR era (2012–2020, n = 1,435). Data from the institutional Society of Thoracic Surgeons National Database was analyzed.ResultsThe median age was 66 years, similar between groups. The post-TAVR group had a statistically higher rate of diabetes, hypertension, dyslipidemia, heart failure, more reoperative SAVR, and lower STS Predicted Risk of Mortality (PROM) (2.0% vs. 2.5%, p < 0.0001). There were more urgent/emergent/salvage SAVRs (38% vs. 24%) and fewer elective SAVRs (63% vs. 76%), (p < 0.0001) in the post-TAVR group. More bioprosthetic valves were implanted in the post-TAVR group (85% vs. 74%, p < 0.0001). Larger aortic valves were implanted (25 vs. 23 mm, p < 0.0001) and more annular enlargements were performed (5.9% vs. 1.6%, p < 0.0001) in the post-TAVR era. Postoperatively, the post-TAVR group had less blood product transfusion (49% vs. 58%, p < 0.0001), renal failure (1.4% vs. 4.3%, p < 0.0001), pneumonia (2.3% vs. 3.8%, p = 0.01), shorter lengths of stay, and lower in-hospital mortality (1.5% vs. 3.3%, p = 0.0007).ConclusionThe approval of TAVR changed the landscape of aortic valve disease management. At a quaternary academic cardiac surgery center with a well-established structural heart program, patients undergoing isolated SAVR in the post-TAVR era had lower STS PROM, more implantation of bioprosthetic valves, utilization of larger valves, annular enlargement, and lower in-hospital mortality. Isolated SAVR continues to be performed in the TAVR era with excellent outcomes. SAVR remains an essential tool in the lifetime management of aortic valve disease.

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Section: Discussionmentioning

confidence: 98%

“…FIGURE 4The median size of the surgical aortic valve implanted increased in the post-TAVR era(25 [23, 27] mm) compared to the pre-TAVR era (23[21,25] mm).…”

mentioning

confidence: 99%

Trends in surgical aortic valve replacement in pre- and post-transcatheter aortic valve replacement eras at a structural heart center

Norton

Ward

Tully

et al. 2023

Front. Cardiovasc. Med.

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“… 12 However, a study done in 2019 comparing SAVR and TAVR showed that TAVR is associated with less prosthesis–patient mismatch and lower transaortic gradients. 13 There are likely several major reasons that contribute to an overall increase in gradients, lower valve area, and higher risk of patient‐prosthesis mismatch (PPM) in surgical patients. First, the engineering of a bioprosthetic surgical valve requires a suture ring which is used to attach the valve prosthesis to the native annulus.…”

Section: Discussionmentioning

confidence: 99%

“…Elevated mean gradients, whether in native or prosthetic valves, are associated with higher mortality and poorer outcomes 12 . However, a study done in 2019 comparing SAVR and TAVR showed that TAVR is associated with less prosthesis–patient mismatch and lower transaortic gradients 13 . There are likely several major reasons that contribute to an overall increase in gradients, lower valve area, and higher risk of patient‐prosthesis mismatch (PPM) in surgical patients.…”

Section: Discussionmentioning

confidence: 99%

A retrospective study on the trends in surgical aortic valve replacement outcomes in the post‐transcatheter aortic valve replacement era

Chahine

Jedeon

Fiocchi

et al. 2022

Health Science Reports

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Background and Aims: Transcatheter aortic valve replacement (TAVR) is the mainstay of treatment of inoperable and severe high-risk aortic stenosis and is noninferior to surgical aortic valve replacement (SAVR) for low-risk and intermediate-risk patients as well. We aim to compare the valve size, area, and transaortic mean gradients in SAVR patients before and after the implementation of TAVR since being approved by the Food and Drug Administration in 2011. Methods: Patients who underwent a bioprosthetic SAVR placement were divided into two groups based on the date of procedure: the early pre-TAVR implementation group (years 2011-2012) and the contemporary post-TAVR group (years 2019-2020). The primary endpoint was the mean gradient across the aortic valve within 16 months of surgery. The secondary endpoints included the difference in valve size and various aortic valve echocardiographic variables. Results: One hundred and thirty patients had their valves replaced in the years 2011-2012 and 134 in the years 2019-2020. The early group had a significantly higher mean gradient (median of 13 mmHg [interquartile range, IQR: 9.3-18] vs. 10 mmHg [IQR: 7.5-13.1], p = 0.001) and a smaller median effective orifice area index (0.8 cm 2 /m 2 [IQR: 0.6-1] vs. 1.1 cm 2 /m 2 [IQR: 0.8-1.3], p < 0.001). The median valve size was significantly smaller in the early group (median of 21 mm [IQR: 21-23] vs. 23 mm [IQR: 22.5-25], p < 0.001). Conclusion:In the contemporary era, surgical patients receive larger valves which translates into lower mean gradients, larger valve area, and lower rates of patientprosthesis mismatch than in previous years before the routine introduction of TAVR.

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“…TAVR has been associated with a decreased risk of PPM compared to SAVR, especially in patients with small aortic annuli. Aalaei-Andabili et al found the incidence of PPM was almost double following SAVR compared to TAVR (54% vs. 29%, p < 0.001), especially among patients receiving a valve size ≤23 mm (SAVR, 65% vs. TAVR, 48%, p =0.048) [ 13 ]. The average aortic valve size implanted in the US is 22 mm [ 3 ], leaving many patients with the risk of PPM, early valve failure, and increased mortality.…”

Section: The Problemmentioning

confidence: 99%

Management of Failed Bioprosthetic Aortic Valves: Mitigating Complications and Optimizing Outcomes

Norton

Ward

Greenbaum

et al. 2022

Journal of Interventional Cardiology

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The use of bioprosthetic prostheses during surgical aortic valve replacements has increased dramatically over the last two decades, accounting for over 85% of surgical implantations. Given limited long-term durability, there has been an increase in aortic valve reoperations and reinterventions. With the advent of new technologies, multiple treatment strategies are available to treat bioprosthetic valve failure, including valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). However, ViV TAVR has an increased risk of higher gradients and patient prosthesis mismatch (PPM) secondary to placing the new valve within the rigid frame of the prior valve, especially in patients with a small surgical bioprosthesis in situ. Bioprosthetic valve fracture allows for placement of a larger transcatheter valve, as well as a fully expanded transcatheter valve, decreasing postoperative gradients and the risk of PPM.

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Impact of Valve Size on Prosthesis–Patient Mismatch and Aortic Valve Gradient After Transcatheter versus Surgical Aortic Valve Replacement

Cited by 3 publications

References 27 publications

Trends in surgical aortic valve replacement in pre- and post-transcatheter aortic valve replacement eras at a structural heart center

Trends in surgical aortic valve replacement in pre- and post-transcatheter aortic valve replacement eras at a structural heart center

A retrospective study on the trends in surgical aortic valve replacement outcomes in the post‐transcatheter aortic valve replacement era

Management of Failed Bioprosthetic Aortic Valves: Mitigating Complications and Optimizing Outcomes

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