Valve Hemodynamics and Clinical Outcomes After Transcatheter Aortic Valve Replacement for a Small Aortic Annulus

Abstract

The hemodynamics and outcomes in patients with a small aortic annulus (SAA) after transcatheter aortic valve replacement (TAVR) with a second-generation transcatheter heart valve remain unclear. We investigated whether TAVR with a Sapien XT (Edwards Lifesciences, Irvine, California) influences postprocedural valve hemodynamics and long-term outcome in high-risk SAA patients compared with surgical aortic valve replacement (SAVR). We retrospectively identified 94 SAA patients who underwent aortic valve replacement (TAVR = 35 and SAVR = 59). SAA was defined as an aortic annulus diameter !20 mm, measured by preprocedural transesophageal echocardiography. The mean age was 80.2 years. The mean Society of Thoracic Surgeons-Predicted Risk of Mortality was 6.8%. The post-procedural peak transvalvular velocity and mean pressure gradient were significantly lower in the TAVR cohort than in the SAVR cohort, whereas the postprocedural aortic valve area was significantly higher in the TAVR cohort. Severe prosthesis-patient mismatch (PPM) occurred less frequently after TAVR than SAVR (TAVR 2.9% versus SAVR 22.0%, P = 0.01). The two-year mortality in SAA patients was similar between the two groups. TAVR with a Sapien XT in SAA patients improved the valve hemodynamics and reduced the incidence of PPM compared with SAVR. TAVR patients had a similar 2-year mortality despite higher risk baseline characteristics. To avoid PPM and the consequent poor outcomes, TAVR can be considered an alternative option to SAVR in high surgical risk patients with SAA.

Transcatheter aortic valve replacement with Evolut R versus Sapien 3 in Japanese patients with a small aortic annulus: The OCEAN‐TAVI registry

“…Transcatheter aortic valve replacement (TAVR) is reportedly advantageous over surgical aortic valve replacement for patients with a small native aortic annulus, owing to fewer incidences of prosthesispatient mismatch (PPM) and the larger effective orifice area (EOA) achieved, associated with the absence of a sewing ring. [1][2][3][4] Valve-invalve (VIV) TAVR has drawn attention as a minimally invasive treatment for patients with degenerative bioprosthesis, 5 for whom use of TAVR will likely increase. In Japan, two different third-generation transcatheter heart valves (THVs) (self-expanding THV, Evolut R, Medtronic, Minneapolis, MN and balloon-expandable THV, Sapien 3, Edwards Lifesciences, Irvine, CA) are used for TAVR.…”

“…Transcatheter aortic valve replacement (TAVR) is reportedly advantageous over surgical aortic valve replacement for patients with a small native aortic annulus, owing to fewer incidences of prosthesis‐patient mismatch (PPM) and the larger effective orifice area (EOA) achieved, associated with the absence of a sewing ring 1‐4 . Valve‐in‐valve (VIV) TAVR has drawn attention as a minimally invasive treatment for patients with degenerative bioprosthesis, 5 for whom use of TAVR will likely increase.…”

Surgical aortic valve replacement in small aortic annulus

“…There are recent studies that have specifically compared TAVR to SAVR among patients with SAA. On short‐term follow‐up, patients who underwent TAVR had a larger EOA, lower mean gradient, and lower rate of severe PPM in comparison to SAVR patients 58,59 . Among patients with SAA, there was no difference between TAVR and SAVR with respect to EOA and rates of PPM, but the mean gradient was lower following TAVR 60 .…”

“…On short-term follow-up, patients who underwent TAVR had a larger EOA, lower mean gradient, and lower rate of severe PPM in comparison to SAVR patients. 58,59 Among patients with SAA, there was no difference between TAVR and SAVR with respect to EOA and rates of PPM, but the mean gradient was lower following TAVR. 60 This association was not present among patients with a larger aortic annulus.…”

Sex-Related Differences in Cardiac Remodeling and Reverse Remodeling After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis in a Japanese Population

“…17,18) It has been reported that severe AS patients receiving TAVI in Japan are much older than those in Europe and the United States. 19,20) The population of patients in this trial had an average age approximately more than five years older than the populations in recent TAVI trials. 6,9,11) Moreover, in contrast to other studies evaluating sex in AS, our male and female groups were similar in terms of REVERSE REMODELING AFTER TAVI age, comorbidity, cardiac risk score, and aortic valve gradients.…”