Reply to the Editor

Abstract

We thank Dr Bozok and colleagues for their useful comments and suggestions to reduce paravalvular leak after transapical aortic valve implantation. In our study based on data from the Italian Registry of Trans-Apical Aortic Valve Implantation,1D’Onofrio A. Rubino P. Fusari M. Salvador L. Musumeci F. Rinaldi M. et al.Clinical and hemodynamic outcomes of “all-comers” undergoing transapical aortic valve implantation: results from the Italian Registry of Trans-Apical Aortic Valve Implantation (I-TA).J Thorac Cardiovasc Surg. 2011; 142: 768-775Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar the incidence of paravalvular leak (trivial and mild) was 38%, and this is consistent with the incidence reported by other series.2Unbehaun A. Pasic M. Dreysse S. Drews T. Kukucka M. Mladenow A. et al.Transapical aortic valve implantation: incidence and predictors of paravalvular leakage and transvalvular regurgitation in a series of 358 patients.J Am Coll Cardiol. 2012; 59: 211-221Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar Reducing the incidence of paravalvular leak is of outmost importance to improve patient outcomes. In fact, it has been demonstrated that the presence of paravalvular aortic regurgitation after transcatheter aortic valve implantation is associated with an increased rate of late mortality and that the effect of aortic regurgitation on mortality is proportional to the severity of the regurgitation. Furthermore, even mild aortic regurgitation is associated with an increased rate of late deaths.3Kodali S.K. Williams M.R. Smith C.R. Svensson L.G. Webb J.G. Makkar R.R. et al.Two-year outcomes after transcatheter or surgical aortic-valve replacement.N Engl J Med. 2012; 366: 1686-1695Crossref PubMed Scopus (1896) Google Scholar Overexpansion of the Sapien valve after deployment might be useful, but it is controversial and should be performed carefully. Many complications can occur after this procedure, including not only coronary ostia occlusion, but also rupture of the aortic annulus and injury to the prosthetic valve leaflets. Furthermore, in our experience, overexpansion of the Sapien valve after deployment is often associated with a small (or none) reduction of the degree of paravalvular regurgitation. We agree with Dr Bozok that asymmetry of the calcium distribution over the leaflets and annulus is a major determinant of paravalvular regurgitation; however, other important causes should be also carefully considered such as correct sizing and correct positioning. Correct sizing needs an experienced multidisciplinary and multimodal (2-dimensional and 3-dimensional transthoracic and transesophageal echocardiography, multidetector computerized tomography scan) evaluation of the annulus dimensions and shape (the annulus is often oval and not circular) and a semiquantitative evaluation of the amount of calcium on the annulus and the leaflets. In fact, for the intermediate annulus diameters, the choice of a larger or a smaller valve depends on the amount of calcium. A larger valve in an extremely calcified annulus can cause rupture of the aortoventricular junction with consequent massive hemorrhage. However, a small valve in a poorly calcified annulus can lead to paravalvular regurgitation or, more dramatically, device embolization. Correct positioning requires experience and a strong synergic cooperation among all the components of the transcatheter aortic valve implantation team. The definition of valve malpositioning includes not only a valve positioned too high or too low, but also a problem of alignment between the valve and longitudinal axis of the aortic annulus. An asymmetric “diagonal” landing of the prosthesis on the annulus might lead to paravalvular regurgitation and to an abnormal stress on the leaflets with a greater potential risk of early structural dysfunction. In conclusion, we believe that even if valve overexpansion might be carefully considered to reduce paravalvular leak, the transcatheter aortic valve implantation results can be increased mainly by improving patient selection, annulus sizing, valve positioning, and cooperation among members, as well as the experience of the transcatheter aortic valve implantation team. Can the success of transcatheter aortic valve implantation be increased?The Journal of Thoracic and Cardiovascular SurgeryVol. 144Issue 2PreviewWe congratulate the authors on their study.1 After application of a size 26 Sapien valve to one third of the patients, the postoperative effective orifice area was noted to be 1.67 cm2 and the geometric size was 2.5 cm2 in the size 21 Sapien valve. This suggests that the balloon should be inflated more. Instead of “hinge-to-hinge” or “virtual ring” calculations, we suggest that an experienced cardiac surgeon can decide which leaflet should be dilated to what degree, while inflating the valve using computed tomography or echocardiography, because the Sapien valve is located at the leaflet and not at the annulus. Full-Text PDF