Abstract
BackgroundA small aortic annulus is associated with increased risk of prosthesis–patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI). Whether specific transcatheter heart valve (THV) designs yield superior hemodynamic performance in these small anatomies remains unclear.MethodsData from 8411 consecutive patients treated with TAVI from May 2012 to April 2019 at four German centers were retrospectively evaluated. A small aortic annulus was defined as multidetector computed tomography-derived annulus area < 400 mm2. TAVI was performed with a balloon-expanding intra-annular (Sapien-3, n = 288), self-expanding intra-annular (Portico, n = 110), self-expanding supra-annular (Evolut, n = 179 and Acurate-Neo, n = 428) and mechanically expanding infra-annular (Lotus, n = 64) THV according to local practice. PPM was defined as indexed effective orifice area ≤ 0.85cm2/m2.ResultsA small annulus was found in 1069 (12.7%) patients. PPM was detected in 38.3% overall with a higher prevalence after implantation of a balloon-expanding intra-annular or mechanically expanding infra-annular THV compared to self-expanding intra- and supra-annular THV. Multivariable analysis linked self-expanding THV (Evolut: Odds ratio [OR] 0.341, Acurate-Neo: OR 0.436, Portico: OR 0.291), postdilatation (OR 0.648) and age (OR 0.968) to lower rates of PPM, while aortic valve calcification was associated with an increased risk (OR 1.001). Paravalvular regurgitation > mild was more frequent after TAVI with self-expanding THV (p = 0.04).ConclusionIn this large contemporary multicenter patient population, a substantial number of patients with a small aortic anatomy were left with PPM after TAVI. Self-expanding supra- and intra-annular THV demonstrated superior hemodynamics in these patients at risk, however at the cost of higher rates of residual paravalvular regurgitation.Graphic abstract
Highlights
MethodsPatient–prosthesis mismatch (PPM) after aortic valve replacement is associated with increased long-term mortality and morbidity [1, 2]
Several strategies were developed to minimize the risk of PPM after surgical aortic valve replacement (SAVR), i.e. aortic root enlargement or implantation of sutureless bioprostheses [3, 4]
Lower rates of PPM were reported after transcatheter aortic valve implantation (TAVI) [5, 6], the prevalence of moderate and severe PPM was described in as many as 35% of patients [7]
Summary
MethodsPatient–prosthesis mismatch (PPM) after aortic valve replacement is associated with increased long-term mortality and morbidity [1, 2]. Lower rates of PPM were reported after transcatheter aortic valve implantation (TAVI) [5, 6], the prevalence of moderate and severe PPM was described in as many as 35% of patients [7]. Recent analyses favored supra-annular transcatheter heart valves (THV) for the treatment of patients with severe aortic stenosis and a small aortic annulus (SAA) [8–10]. A small aortic annulus is associated with increased risk of prosthesis–patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI). Multivariable analysis linked self-expanding THV (Evolut: Odds ratio [OR] 0.341, Acurate-Neo: OR 0.436, Portico: OR 0.291), postdilatation (OR 0.648) and age (OR 0.968) to lower rates of PPM, while aortic valve calcification was associated with an increased risk (OR 1.001). Self-expanding supra- and intra-annular THV demonstrated superior hemodynamics in these patients at risk, at the cost of higher rates of residual paravalvular regurgitation
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