Prosthesis–patient mismatch in high-risk patients with severe aortic stenosis: A randomized trial of a self-expanding prosthesis

Abstract

In patients with high surgical risk and severe aortic stenosis, severe PPM is more common in patients treated with SAVR than those treated with TAVR. Patients with severe PPM are a greater risk for death and acute kidney injury than patients without severe PPM.

A Paradox between LV Mass Regression and Hemodynamic Improvement after Surgical and Transcatheter Aortic Valve Replacement

“…7 This is paradoxical given the fact that prosthetic aortic valve gradients are higher and severe PPM is more frequent after SAVR compared to TAVR, again demonstrated in this cohort. 11,17 The degree of LV mass regression seen after TAVR in our study was comparable to a similar study evaluating LV remodeling after CoreValve bioprosthesis implantation. 18 This paradox appears to be related to significant reductions in LVEDD and SV soon after SAVR which did not occur after TAVR.…”

“…7,8 The CoreValve US Pivotal Trial using a self-expanding valve in a larger number of patients with severe AS and high surgical risk 9 yielded a similar paradoxical finding of a faster and greater reduction of LV mass in the SAVR group when LV mass was calculated by a standard mass formula. 10,11 The purpose of this analysis was to identify reasons for this paradox by using serial echocardiography data analyzed by an independent echocardiography core laboratory.…”

The Left Ventricular Mass Regression Paradox following Surgical Valve Replacement: A Real Phenomenon or a Mathematical Glitch?

“…Furthermore, although TAVR patients harbor better indexed valve areas and gradients compared to SAVR patients, they also have more paravalvular regurgitation, which may contribute to hinder or slow the regression of LV hypertrophy in these patients. [5][6][7]12 In the study by Kadkhodayan and colleagues, 7 the results remained similar, i.e. the LV mass regression was more important in SAVR than in TAVR, even after excluding the patients with paravalvular regurgitation.…”

“…4 Recent studies report that PPM is more frequent and more often severe following surgical AVR (SAVR) than transcatheter AVR (TAVR), and this translated into less LV mass regression and worse survival than those without PPM. 4 The paradox of LV mass regression following SAVR In the PARTNER 1A trial and the Pivotal CoreValve trial, [5][6][7][8] LV mass regression was faster and greater after SAVR compared to TAVR despite higher transaortic pressure gradients and more frequent severe PPM after SAVR. The purpose of the article by Kadkhodayan and colleagues 7 published in this first issue of Structural Heart was to identify the reasons for this paradox by using the serial echocardiography data analyzed by an independent echocardiography core laboratory in patients with severe AS randomized to SAVR vs. TAVR with the CoreValve bioprosthesis.…”

“…[5][6][7]12 Again, the geometric assumptions of the ASE formula may have overestimated the LV mass regression in the SAVR arm because of the postoperative decrease in LV end-diastolic diameter (Figure 1). Furthermore, although TAVR patients harbor better indexed valve areas and gradients compared to SAVR patients, they also have more paravalvular regurgitation, which may contribute to hinder or slow the regression of LV hypertrophy in these patients.…”