Transcatheter aortic valve replacement for pure aortic valve regurgitation: "on-label" versus "off-label" use of TAVR devices.

Abstract

Transcatheter aortic valve replacement (TAVR) has become the mainstay of treatment for aortic stenosis in patients with high surgical risk. Pure aortic regurgitation (PAR) is considered a relative contraindication for TAVR; however, TAVR is increasingly performed in PAR patients with unfavorable risk profile. Herein, we aim to summarize available data on TAVR for PAR with special emphasis on "on-label" versus "off-label" TAVR devices. Pubmed was searched for studies of patients undergoing TAVR for PAR. Primary outcome was 30day-mortality. Pooled estimated event rates were calculated. Twelve studies including a total of 640 patients were identified until December 2017. Among these, 208 (33%) patients were treated with devices with CE-mark approval for PAR ("on-label"; JenaValve and J valve). Overall, the procedural success rate was 89.9% (95% CI 81.1-96.1%; I2 80%). Major bleeding was reported in 6.4% (95% CI 2.9-10.8%; I2 48%). All-cause mortality at 30days was 10.4% (95% CI 7.1-14.2%; I2 20%). Stroke occurred in 2.2% (95% CI 0.9-3.9%; I2 0%). A permanent pacemaker was required in 10.7% (95% CI 7.3-14.6%; I2 23%). At 30days after TAVR, ≥ moderate AR post-interventional was observed in 11.5% (95% CI 2.9-23.6%; I2 90%). In the "on-label"-group, success rate was 93.0% (95% CI 85.9-98.1%; I2 52%). 30-day-mortality was 9.1% (95% CI 3.7-16.0%; I2 36%). More than trace AR was present in 2.8% (95% CI 0.1-7.6%; I2 0%). Compared to first-generation devices, second-generation devices were associated with significantly lower 30-day-mortality (r = - 0.10; p = 0.02), and significantly higher procedural success rates (r = 0.28; p < 0.001). Compared to other second-generation devices, the use of J valve or JenaValve was not associated with altered mortality (r = 0.04; p = 0.50), rates of > trace residual AR (r = - 0.05; p = 0.65) but with a significantly higher procedural success (r = 0.15; p = 0.042). Based on this summary of available observational data TAVR for PAR is feasible and safe in patients deemed inoperable. First-generation TAVR devices are associated with inferior outcome and should be avoided. The "on-label" use of PAR-certified TAVR devices is associated with a significantly higher procedural success rate and might be favorable compared to other second-generation devices.