Residual Aortic Regurgitation Research Articles

Early failure of quadricuspid aortic valve tricuspidization due to dehiscence of approximating coronary cusps.

A 48-year-old woman diagnosed with aortic regurgitation showing a quadricuspid aortic valve (QAV) underwent repair with tricuspidization. Two non-coronary cusps (NCC) with fenestrations were detected intraoperatively. Tricuspidization of QAV was performed by approximating the two NCCs via interrupted sutures. The aortic annulus was plicated by subcommissural annuloplasty. The residual aortic regurgitation was mild, with a vena contracta of 2.1mm. On postoperative day 5, echocardiography demonstrated a new regurgitation from the middle of the neo-NCC, and increased central regurgitation. Intraoperative findings showed the dehiscence of approximating sutures of the neo-NCC. Mechanical valve replacement was performed uneventfully.

Is postdilatation useful after implantation of the Edwards valve?

Few data are available about postdilatation (PD) for the treatment of significant paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation of the Edwards valve. A total of 470 patients, aged 83.4 ± 6.4 yrs, with logistic European System for Cardiac Operative Risk Evaluation 21.9 ± 12.3, undergoing transcatheter aortic valve implantation with the Edwards valve were evaluated. PD was performed using the balloon delivery system when significant paravalvular AR was identified. The diameter of the valve was measured from cine acquisition at three different levels. PD was performed in 49 (10.4%) patients with grade 2, 3, or 4 AR as 42.1%, 55.3%, and 2.6%, respectively. After PD, a reduction of at least 1 degree of AR was achieved in 81.5% of cases. Residual AR grades 2, 3, and 4 were observed in 36.8%, 10.5%, and 0%, respectively. A significant increase in the prosthesis diameter was observed at the three valve levels (absolute Δ 3.5%-5.4%, P.< 0.01). For the 23 mm valve, mid level of valve increased from 23.0 ± 0.4 to 24.1 ± 0.5 mm (P < 0.01) and for the 26 mm, from 25.2 ± 0.9 to 26.6 ± 0.9 mm (P < 0.01). Occurrence of annulus rupture (4.1% vs. 1.7%, P = 0.24), cerebrovascular accidents (2.0% vs. 2.1%, P = 0.72), need for new pacemaker (8.2% vs. 5.5%, P = 0.31), and 30-day composite endpoint (24.5% vs. 20.2%, P = 0.48) were not significantly different between PD and non-PD groups. PD for the treatment of significant paravalvular leak proved to be a feasible treatment allowing a significant increase in valve size and decrease in PVL without increase in stroke rates. This promising approach needs further confirmation.

Does residual aortic regurgitation after transcatheter aortic valve implantation increase mortality in all patients? The importance of baseline natriuretic peptides

BackgroundAortic regurgitation (AR) is an important complication of transcatheter aortic valve implantation (TAVI) and even moderate AR is associated with increased mortality after TAVI. The association with decreased survival is unclear. We aimed to analyse the impact of AR after TAVI as a function of baseline NT-proBNP. MethodsWe included 236 consecutive patients implanted in our centre with the SAPIEN and SAPIEN XT valves, via the transfemoral route. AR was evaluated by transthoracic echocardiography. NT-proBNP was measured 24h before implantation and patients were divided according to the median value. ResultsMedian age was 85years (80–89) and 137 (58.1%) were women. Patients with high NT-proBNP had lower left ventricular ejection fraction: 52% (35–65) vs. 63% (55–70), p<0.001, larger telediastolic diameters: 56mm (49–61) vs. 52mm (46–56), p=0.01, and more severe aortic stenosis: 0.62±0.15cm2 vs. 0.70±0.2cm2, p<0.001. Pre-procedural moderate or severe AR (42% vs. 26%, p=0.013) and mitral regurgitation (56% vs. 36%, p=0.004) were more common in the high NT-proBNP group. After TAVI, moderate or severe AR occurred in 26% of patients and was associated with increased 2-year mortality only in the low NT-proBNP group, while patients in the high NT-proBNP group were not affected. ConclusionsModerate or severe AR after TAVI was not associated with increased 2-year mortality in patients with high baseline NT-proBNP. Our data suggest that the impact of AR after TAVI is absent in patients with significant pre-procedural AR or mitral regurgitation and more severe aortic stenosis.

Balloon-Expandable Prostheses for Transcatheter Aortic Valve Replacement

The implantation of a transcatheter heart valve (THV) through a balloon-expandable system played a major role in the early stages of transcatheter aortic valve replacement (TAVR). The technology consists of sewing a foldable biological cardiac valve inside a metallic stent frame, and then crimping the device into a balloon in order to implant the valve at the level of the aortic annulus through balloon inflation. The use of balloon-expandable valves underwent a rapid expansion in the years following the pioneering experience of 2002, and recent large multicenter trials and registries have confirmed the safety and efficacy of TAVR using balloon-expandable valves. The randomized Placement of Aortic Transcatheter Valves (PARTNER) trial showed both the superiority and non-inferiority of TAVR with the balloon-expandable Edwards-Sapien system compared to medical treatment (non-operable patients) and surgical aortic valve replacement (high risk patients), respectively. Balloon-expandable valves have been associated with excellent hemodynamic results (residual mean gradient <15 mm Hg in most cases), though residual paravalvular aortic regurgitation is frequent (trivial or mild in the majority of patients, moderate or severe in <10%). Valve durability studies with up to 5-year follow-up have shown maintained valve hemodynamics over time with only a minimal decrease in valve area and no increase in aortic regurgitation. Future improvements in the balloon-expandable THV technology such as implementing anti-paravalvular leak features (ex. Sapien 3 valve), and showing its efficacy for the treatment of non-high risk patients (ongoing PARTNER II trial) will probably lead to broader use in a lower risk population in the near future.

Paravalvular aortic regurgitation after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a rapidly evolving technology that has been accepted as a treatment option in patients with severe aortic stenosis who are not suitable for or are at high risk for conventional surgery. Randomized trials have shown that TAVR decreases mortality and improves quality of life in patients who are not suitable for conventional surgery and that TAVR is not inferior to standard surgery in operable but high- risk patients. However, TAVR has several important limitations, the most prominent of which is residual paravalvular aortic regurgitation (PAR). The purpose of this review is to present the mechanism, incidence, assessment, and treatment of PAR after TAVR.

Comparison of the Effectiveness of Transcatheter Aortic Valve Implantation in Patients With Stenotic Bicuspid Versus Tricuspid Aortic Valves (from the German TAVI Registry)

Patients with bicuspid aortic valves (BAVs) are considered a relative contraindication to transcatheter aortic valve implantation (TAVI). One of the main reasons is the presumed risk for residual aortic regurgitation (AR). However, case reports and small case series have suggested that TAVI can be successfully performed with acceptable clinical outcomes in high-risk patients with BAV. Within the large German TAVI Registry, we sought to evaluate TAVI in older high-risk patients with BAV. From January 2009 to June 2010, a total of 1,424 patients with severe aortic stenosis undergoing TAVI were prospectively enrolled into the German TAVI Registry. For the present analysis, patients with valve-in-valve procedures were excluded and those with BAV (n = 38, 3%) were compared with those with tricuspid aortic valve (TAV; n = 1357, 97%). Patient characteristics did not markedly differ and procedural success was very high in both groups. There was a higher rate of relevant AR (≥II) after TAVI among patients with BAV (25 vs 15%, p = 0.05), whereas pacemakers were more often implanted in patients with TAV (17% vs 35%, p = 0.02). Thirty-day mortality rate was similar in both cohorts (11% vs 11%). In a Cox proportional regression analysis, BAV was not associated with higher 1-year mortality rate (hazard ratio 0.64, 95% confidence interval 0.29 to 1.41). In selected patients with BAV, TAVI can be performed with a satisfactory clinical result. Although the risk for relevant AR seems to be greater among patients with BAV, 30-day and 1-year mortality rates were not elevated compared with patients with TAV.

Incidence and progression of mild aortic regurgitation after Tirone David reimplantation valve-sparing aortic root replacement

The study objective was to determine whether recurrent or residual mild aortic regurgitation, which occurs after valve-sparing aortic root replacement, progresses over time. Between 2003 and 2008, 154 patients underwent Tirone David-V valve-sparing aortic root replacement; 96 patients (62%) had both 1-year (median, 12 ± 4 months) and mid-term (62 ± 22 months) transthoracic echocardiograms available for analysis. Age of patients averaged 38 ± 13 years, 71% were male, 31% had a bicuspid aortic valve, 41% had Marfan syndrome, and 51% underwent aortic valve repair, predominantly cusp free margin shortening. Forty-one patients (43%) had mild aortic regurgitation on 1-year echocardiogram. In 85% of patients (n=35), mild aortic regurgitation remained stable on the most recent echocardiogram (median, 57 ± 20 months); progression to moderate aortic regurgitation occurred in 5 patients (12%) at a median of 28 ± 18 months and remained stable thereafter; severe aortic regurgitation developed in 1 patient, eventually requiring reoperation. Five patients (5%) had moderate aortic regurgitation at 1 year, which did not progress subsequently. Two patients (2%) had more than moderate aortic regurgitation at 1 year, and both ultimately required reoperation. Although mild aortic regurgitation occurs frequently after valve-sparing aortic root replacement, it is unlikely to progress over the next 5 years and should not be interpreted as failure of the valve-preservation concept. Further, we suggest that mild aortic regurgitation should not be considered nonstructural valve dysfunction, as the 2008 valve reporting guidelines would indicate. We need 10- to 15-year follow-up to learnthe long-term clinical consequences of mild aortic regurgitation early after valve-sparing aortic root replacement.

Acute Outcomes after Introduction of a Standardized Clinical Assessment and Management Plan (SCAMP) for Balloon Aortic Valvuloplasty in Congenital Aortic Stenosis

Standardization of care can reduce practice variation, optimize resource utilization, and improve clinical outcomes. We have created a standardized clinical assessment and management plan (SCAMP) for patients having balloon aortic valvuloplasty (BAV) for congenital aortic stenosis (AS). This study compares acute outcomes of BAV at our institution before and after introduction of this SCAMP. In this retrospective matched cohort study, each SCAMP patient was matched to four historical controls. Outcomes were categorized based on the combination of residual AS and aortic regurgitation (AR) as: (1) Optimal: gradient ≤ 35 mm Hg and trivial or no AR; (2) Adequate: gradient ≤ 35 mm Hg and mild AR; (3) Inadequate: gradient > 35 mm Hg and/or moderate or severe AR. All 23 SCAMP patients achieved a residual AS gradient ≤ 35 mm Hg; the median residual AS gradient for the SCAMP group was lower (25 [10-35] mm Hg) than in matched controls (30 [0-65] mm Hg; P = 0.005). The two groups did not differ with regard to degree of AR grade after BAV. Compared with controls, SCAMP patients were more likely to have an optimal result and less likely to have an inadequate result (52% vs. 34% and 17% vs. 45%, respectively; P = 0.02) CONCLUSIONS: A SCAMP for BAV resulted in optimal acute results in half of the initial 23 patients enrolled, and outcomes in this group were better than those of matched historical controls. Whether these improved acute outcomes translate into better long-term outcomes for this patient population remains to be seen.

Predictores de mortalidad hospitalaria y a medio plazo tras el reemplazo valvular aórtico transcatéter: datos del registro nacional TAVI 2010-2011

Introduction and objectivesThe treatment of severe symptomatic aortic stenosis has been revolutionized by the technique of transcatheter valve replacement. The purpose of this study was to present the outcomes and predictors of mortality in patients enrolled between 2010 and 2011 in the Transcatheter Aortic Valve Replacement National Registry. MethodsWe collected 131 preprocedural, 31 periprocedural, and 76 follow-up variables, and analyzed the immediate implant success rate, the 30-day safety endpoint, and all-cause 30-day and mid-term (mean follow-up, 244 days) mortality. ResultsFrom January 2010 to December 2011, a total of 1416 patients were included: 806 with Edwards valves and 610 with CoreValves. The implant success and 30-day mortality rates were 94% and 8%, respectively, without differences between types of valves and approaches. The 30-day safety endpoint and mid-term mortality rates were 14% and 16%, respectively, which were also similar between groups. The presence of comorbidities (renal failure, peripheral vascular disease, ejection fraction, and atrial fibrillation), the need for conversion to surgery, and at least moderate aortic regurgitation after transcatheter aortic valve implantation were identified as independent predictors of in-hospital and mid-term mortality. ConclusionsThe prognosis of valve implant patients could be improved by including comorbidities in patient selection and by minimizing the degree of residual aortic regurgitation to optimize the results of the procedure.Full English text available from:www.revespcardiol.org/en

In-hospital and Mid-term Predictors of Mortality After Transcatheter Aortic Valve Implantation: Data From the TAVI National Registry 2010-2011

Introduction and objectivesThe treatment of severe symptomatic aortic stenosis has been revolutionized by the technique of transcatheter valve replacement. The purpose of this study was to present the outcomes and predictors of mortality in patients enrolled between 2010 and 2011 in the Transcatheter Aortic Valve Replacement National Registry. MethodsWe collected 131 preprocedural, 31 periprocedural, and 76 follow-up variables, and analyzed the immediate implant success rate, the 30-day safety endpoint, and all-cause 30-day and mid-term (mean follow-up, 244 days) mortality. ResultsFrom January 2010 to December 2011, a total of 1416 patients were included: 806 with Edwards valves and 610 with CoreValves. The implant success and 30-day mortality rates were 94% and 8%, respectively, without differences between types of valves and approaches. The 30-day safety endpoint and mid-term mortality rates were 14% and 16%, respectively, which were also similar between groups. The presence of comorbidities (renal failure, peripheral vascular disease, ejection fraction, and atrial fibrillation), the need for conversion to surgery, and at least moderate aortic regurgitation after transcatheter aortic valve implantation were identified as independent predictors of in-hospital and mid-term mortality. ConclusionsThe prognosis of valve implant patients could be improved by including comorbidities in patient selection and by minimizing the degree of residual aortic regurgitation to optimize the results of the procedure.

Desinserción parcial de válvula tricúspide para cierre de comunicación interventricular

IntroductionVentricular septal defect closure through the right atrium might be cumbersome in the presence of redundant subvalvar apparatus. Partial tricuspid valve detachment to ease the defect closure is presented. MethodsRetrospective review of 156 patients with ventricular septal defect (82 isolated, 74 Fallot). 20 cases (9 isolated, 11 Fallot) had the tricuspid valve detached (12,8). Mean age and weight was 10,6 months and 7,13kg, respectively. The anterior tricuspid leaflet was electively, partially detached, thus providing a straightforward closure of the defect with Dacron patch (19 patients) or directly (1). Associated procedures: mid-ventricle muscle bundle resection (2), aortic valve re-attachment (2), Alfieri stitch (1) and mitral commisurotomy (1). ResultsMean extracorporeal time was 107minutes (range 61-153) and mean ischemic time was 58minutes (range 31-99). No residual ventricular septal defect, tricuspid regurgitation or aortic regurgitation was detected in intra-operative echographic assessment. One patient died due to sepsis. Another patient had a definite pacemaker implanted for complete heart block. Mean follow-up was 25 months, with no residual defects. ConclusionsPartial detachment of the anterior tricuspid leaflet is useful for right atrium closure of ventricular septal defect in difficult cases. This approach is optimal, rendering good results and little morbidity.

Predictores de mortalidad hospitalaria y a medio plazo tras el reemplazo valvular aórtico transcatéter: datos del registro nacional TAVI 2010-2011

Introduction and objectivesThe treatment of severe symptomatic aortic stenosis has been revolutionized by the technique of transcatheter valve replacement. The purpose of this study was to present the outcomes and predictors of mortality in patients enrolled between 2010 and 2011 in the Transcatheter Aortic Valve Replacement National Registry. MethodsWe collected 131 preprocedural, 31 periprocedural, and 76 follow-up variables, and analyzed the immediate implant success rate, the 30-day safety endpoint, and all-cause 30-day and mid-term (mean follow-up, 244 days) mortality. ResultsFrom January 2010 to December 2011, a total of 1416 patients were included: 806 with Edwards valves and 610 with CoreValves. The implant success and 30-day mortality rates were 94% and 8%, respectively, without differences between types of valves and approaches. The 30-day safety endpoint and mid-term mortality rates were 14% and 16%, respectively, which were also similar between groups. The presence of comorbidities (renal failure, peripheral vascular disease, ejection fraction, and atrial fibrillation), the need for conversion to surgery, and at least moderate aortic regurgitation after transcatheter aortic valve implantation were identified as independent predictors of in-hospital and mid-term mortality. ConclusionsThe prognosis of valve implant patients could be improved by including comorbidities in patient selection and by minimizing the degree of residual aortic regurgitation to optimize the results of the procedure.

Postdilatation for treatment of perivalvular aortic regurgitation after transcatheter aortic valve implantation

The study is made to describe the efficacy and safety of balloon postdilatation (BPD) for the treatment of residual aortic regurgitation (RAoR) after transcatheter aortic valve implantation (TAVI). A single-center observational study is made with 157 consecutive patients accepted to TAVI. The patients were divided into two groups (no BPD-period and BPD-period). Before BPD, RAoR ≥ 2 was seen in 25% of the patients in group 1 and in 29% of the patients in group 2 (P ≥ 0.593). BPD was carried out in 95% (n = 21) of the patients in group 2 with RAoR ≥ 2. Regurgitation improved one grade in 68% of the cases (n = 15), 2 grades in 14% (n = 3), and remained without change in 18% (n = 4). RAoR < 2 was achieved in 91% (n = 73) of the patients in group 2 versus 75% (n = 58) in group 1 (RR = 0.35, 95% CI 0.16-0.80, P = 0.013). We recorded no aortic ring ruptures, damage to the device or displacements. Slight central regurgitation not present before BPD was registered in one case. BPD offers a very good safety profile and reduces RAoR in a large percentage of cases. BPD should be considered for the treatment of moderate to severe RAoR following TAVI.

Is post dilatation useful after implantation of the Edwards valve?

Background: Little data is available about post-dilatation (PD) for the treatment of significant paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) of the Edwards valve. Methods and results: A total of 470 patients, aged 83.4±6.4years, logistic Euroscore 21.9±12.3, undergoing TAVI with the Edwards valve were evaluated. PD was performed using the balloon delivery system when significant paravalvular AR was identified. The diameter of the valve was measured from cine acquisition at 3 different levels. PD was performed in 49 patients (10.4%) with grade 2, 3 or 4 AR in 42.1%, 55.3%, and 2.6%, respectively. After PD, a reduction of at least 1 degree of AR was achieved in 81.5% of cases (residual AR grade 2, 3 and 4 in 36.8%, 10.5%, and 0%, respectively). A significant increase in the prosthesis diameter was observed at the 3 valve levels (AbsoluteΔ3.5%-5.4%, p<0.01). For the 23mm valve, mid level of valve increased from 23.0±0.4 to 24.1±0.5mm (p<0.01) and for the 26mm, from 25.2±0.9 to 26.6±0.9mm (p<0.01). Occurrence of annulus rupture (4.2 vs 1.7%, p=0.24), cerebrovascular accidents (2.6 vs 2.4%, p=0.63), need for new pacemaker (8.3 vs 4.3%, p=0.31) and 30-day composite endpoint (25.5 vs 21.3%, p=0.50) were similar between PD and non PD group. Conclusions: PD for the treatment of significant paravalvular leak after Edwards valve implantation is associated with a significant increase in valve diameter and decrease by at least one AR grade in 81.5% of cases. This promising approach may improve long-term outcome and warrants further investigation.

Dynamic characterization of aortic annulus geometry and morphology with multimodality imaging: Predictive value for aortic regurgitation after transcatheter aortic valve replacement

Patients undergoing transcatheter aortic valve replacement (TAVR), as compared with those undergoing surgical aortic valve replacement (AVR), have higher postprocedural aortic regurgitation (AR), associated with higher mortality. We hypothesized that reduced annular deformation is associated with higher postprocedural AR and sought to assess incremental value of assessment of aortic annular deformation in prediction of post-TAVR AR. We included 87 patients with high-risk severe aortic stenosis (AS) (81 ± 10 years, 54% men) who underwent preprocedural echocardiography and contrast-enhanced (4-dimensional) multidetector computed tomography (MDCT) of the aortic root, followed by TAVR (n = 55) or surgical AVR (n = 32). On MDCT, minimal/maximal annular circumference, circumferential deformation (maximum-minimum over cardiac cycle), and eccentricity (largest/smallest diameter during systole) were calculated. Degree of commissural/annular calcification was graded semiquantitatively (scale 1-3). Oversizing/undersizing of the prosthesis during TAVR was assessed. Pre-AVR aortic valve area (0.6 ± 0.1 vs 0.6 ± 0.1 cm(2)), mean aortic valve gradient (46 ± 14 vs 45 ± 11 mm Hg), AR (1 ± 0.8 vs 0.9 ± 0.7), maximal annular circumference (8 ± 1 vs 7.9 ± 0.8 cm), annular deformation (0.3 ± 0.1 vs 0.3 ± 0.1 cm), eccentricity (1.2 ± 0.1 vs 1.2 ± 0.1), commissural (2.1 ± 0.6 vs 2 ± 0.7), and annular calcification scores (1.7 ± 0.8 vs 1.7 ± 0.8) were similar in TAVR and surgical AVR groups (P = not significant). A higher proportion of patients had ≥ mild AR in the TAVR than in the surgical AVR group (58% vs 34%; P < .03). In TAVR patients, reduced annular deformation (P = .01) predicted postprocedural AR, in addition to prosthesis undersizing (P = .03) and higher annular calcification (P = .03). Residual post-TAVR AR is predicted by reduced aortic annular deformity, higher annular calcification, and prosthesis undersizing. Pre-TAVR 4-dimensional annular assessment aids in prediction of post-TAVR AR.

Transcatheter implantation of self-expanding valve for failed stentless aortic root bioprosthesis

Although repeat aortic valve replacement (AVR) remains the standard treatment for failed bioprostheses, the feasibility of transcatheter aortic valve implantation (TAVI) has also been demonstrated. We report the successful implantation of a CoreValveTM self expanding aortic prosthesis (Medtronic, Inc) in a patient with a degenerated BioConduitTM stentless valve conduit (Shelhigh, Inc). A 63 year-old man was admitted due to NYHA class IV heart failure symptoms. He had a history of triple percutaneous coronary intervention followed by AVR plus LIMA to LAD grafting. Two years after the first surgery, acute dissection of the ascending aorta occurred and the mechanical valve along with the proximal ascending aorta were replaced by a stentless 25 mm valve conduit. Postoperative mediastinitis and atrio-ventricular block warranted sternum refixation and pacemaker implantation. Another year later, the patient underwent conservative treatment for prosthetic valve endocarditis. On current admission, transthoracic and transoesophageal echocardiography (TTE, TEE) revealed left ventricle (LV) end-diastolic diameter (EDD) of 62 mm and ejection fraction (EF) of 25%. Bioprosthetic cusps were opening well but seemed perforated and had attached two additional structures of ultrasound intensity, irregular shape and high mobility corresponding to organised bacterial vegetations. Consequently, severe aortic regurgitation (AR) was present. On coronary angiography, the arterial graft was occluded and no revascularisation within native coronaries was required. The unfavourable anatomical environment expected after mediastinitis accompanied by high STS scoring (16%) and wide peripheral arteries contributed to a decision to reject reoperation in favour of the transcatheter approach. On multi-detector computed tomography (MDCT), the prosthesis length was 45 mm with significant angulation of neighbouring ascending aorta and coronaries reimplanted 12 mm and 17 mm above the valve (Fig. 1). Laboratory findings excluded active infective endocarditis. After induction of general anaesthesia, a Prostar XL (Abbott) device was introduced into the right common femoral artery. Next, a 26 mm CoreValve prosthesis (the size had been selected according to the inner BioConduit diameter of 22 mm by TEE, standard delivery system) was positioned and deployed in a retrograde manner. Lack of fluoroscopy markers such as calcifications or rigid ring rendered the procedure more TEE-dependent. After completion, no transprosthetic gradient was measured and residual paravalvular AR was trivial. Nevertheless, deficient expansion of the stent frame distal part within the non-pliable BioConduit was noted. The time from arterial puncture to closure was 65 min with 22 min of fluoroscopy, and 180 mL of contrast agent was used. The post-procedural course was uneventful and the patient remained asymptomatic at 12-month follow-up. A remarkable improvement in LV performance was noted, with EDD of 54 mm and EF of 56% by TTE. Repeated MDCT visualised uncompromised coronaries ostia and persistent distal stent frame deformation. Proximal circularity remained however unaffected, which corresponded to the valve’s excellent function (Figs. 2, 3). Initial balloon valvuloplasty may optimise transcatheter valve stent alignment at the expense of degenerated bioprosthesis fragmentation and peripheral embolisation. The anticipated fragility of the thin-walled bioprosthetic cuff further added to our refraining from the manoeuvre. Lack of natural aorta sinus widening in patients with full root prostheses renders coronary flow impairment during TAVI more likely. This was avoided by careful positioning of the CoreValve sealing skirt below the coronaries’ ostia.

Reply to Wang

We are thankful to Dr Wang [1] for his positive comments on our manuscript as well as his very pertinent question. As he pointed out, we observed a higher rate of stroke in the immediate postoperative period in the group with residual aortic regurgitation (AR), which, however, did not reach statistical significance [2]. Our study was aimed at assessing the impact of residual AR on long-term mortality, for which we have complete data accessible through the Quebec Civil Registry. Unfortunately, long-term rates of complications such as strokes are less readily available, but we do have long-term follow-up data for 64.6% of the AR ≤1 group (median follow-up 4.6 years) and 76.3% of the group with AR >1 (median follow-up 4.7 years). Analysis of those sub-groups revealed no statistically significant difference in freedom from neurological events at 1 (97.3 vs 97.9%), 3 (95.5 vs 95.5%), 5 (93.2 vs 95.5%) and 10 years (89.1 vs 90.3%), respectively (P = 0.72). Of note, a similar incidence of stroke was observed despite a higher percentage of patients receiving mechanical valves in the AR >1 group than in the AR ≤1 group (28.4 vs 6.4%, P < 0.01). The mechanism suggested by Dr Wang to explain potentially higher rates of stroke in patients with residual AR in transcatheter aortic valve implantation [3] remains intuitive and, although not supported by this post hoc sub-group analysis with its inherent limitations, should be verified in a larger study.

Incidence, outcome and correlates of residual paravalvular aortic regurgitation after transcatheter aortic valve implantation and importance of haemodynamic assessment

Residual paravalvular aortic regurgitation (PAR) after transcatheter aortic valve implantation (TAVI) is common. We therefore evaluated incidence, determinants and outcome of PAR after TAVI. Data from 167 consecutive transcatheter TAVI patients were analysed. PAR was graded by angiography and the pressure gradient between diastolic aortic pressure and left ventricular end-diastolic pressure (∆PDAP-LVEDP) after implantation. TAVI was technically successful in all patients. Mortality was 9% and 20% at 30 days and one year, respectively. Post-procedural PAR was absent in 54 patients (32.3%). Mild PAR was found in 89 (53.3%), moderate in 21 (12.6%), and moderate-to-severe in three patients (1.8%). Cardiovascular mortality at 30 days and one year was increased in patients with moderate and moderate-to-severe PAR compared to patients with no and mild PAR (46% vs. 4% and 73% vs. 7%, respectively, p<0.001). Receiver operating characteristic curve analysis suggested ∆PDAP-LVEDP ≤18 mmHg as a novel predictor of mortality, with an area under the curve of 0.97. In patients undergoing TAVI, moderate and moderate-to-severe PAR was observed in 14.4% and associated with increased cardiovascular mortality. A pressure gradient ∆PDAP-LVEDP≤18 mmHg carries adverse prognosis and requires further intervention.

First-in-Man Transfemoral Transcatheter Aortic Valve Implantation for Severe Aortic Regurgitation in a Patient with Left Ventricular Assist Device

Purpose Patients with left ventricular assist device (LVAD) may develop significant aortic regurgitation (AR) and require high-risk surgical intervention. Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic alternative for patients with severe aortic stenosis not amenable for surgery but has also been used in high risk patients for pure AR with good results. We report the first-in-man case of transfemoral (TF) TAVI in an LVAD patient with severe AR. Methods and Materials A 55 year old female with severe idiopathic dilated cardiomyopathy underwent HeartMate II LVAD implantation on November 2010 as bridge to transplant. Following a hemodynamic uneventful one year at home she gradually developed symptoms of severe left heart failure and echo showed severe non calcified AR. Our local Heart Team recommended TF TAVI as the preferred option and after discussing the options the patient gave her consent for that approach. The procedure was performed on August 8, 2012, under mild sedation without reduction or interruption of the LVAD rotation speed (9400 rpm). The right femoral artery was used for access under local anesthesia and an 18Fr guiding sheath was introduced percutaneously. No pre-dilation of the aortic valve was performed. A stiff guide-wire was placed in the left ventricle, carefully avoiding its entrapment in the LVAD apical inflow cannula, and a 29mm CoreValve (Medtronic, Minneapolis, MN) was implanted without need for rapid pacing. Aortography showed minimal residual AR and no blockage of the LVAD outflow graft in the ascending aorta. The patient was stable hemodynamicaly throughout the procedure and recovered with no complications. Echo on the second post-TAVI day showed no residual AR and she was discharged home. On 3 months follow up her clinical status has improved significantly and she remains with no AR on repeat echo studies. Results TF TAVI should be considered as a safe and viable solution for severe AR in LVAD patients.

Aortic regurgitation after transcatheter aortic valve implantation: mechanisms and implications.

In recent years, transcatheter aortic valve implantation (TAVI) has become an established treatment option for selected high-risk patients with severe aortic stenosis (AS). Favorable results with regard to both hemodynamics and clinical outcome have been achieved with transcatheter valves. Aortic regurgitation (AR) remains a major concern after TAVI. Echocardiography is the imaging modality of choice to assess AR in these patients due to its wide accessibility and low cost. Mostly mild residual AR has been observed in up to 70% of patients. However, as even a mild degree of AR has been associated with a decreased survival up to two years after TAVI, accurate evaluation and classification of AR is important. AR in transcatheter valves can be divided into three types according to different pathophysiological mechanisms. Besides the well-known transvalvular and paravalvular forms of regurgitation, a third form termed supra-skirtal has recently been observed. A thorough understanding of AR in transcatheter valves may allow to improve device design and implantation techniques to overcome this complication. The aim of this review is to provide an overview of the three types of AR after TAVI focussing on the different pathophysiological mechanisms.