Self-expanding Transcatheter Aortic Valve Replacement Research Articles

Five-year outcomes with self-expanding versus balloon-expandable transcatheter aortic valve replacement in patients with left ventricular systolic dysfunction

Abstract Background The importance of transcatheter heart valve (THV) design on clinical outcome in patients with aortic stenosis (AS) and left ventricular (LV) systolic dysfunction remains unknown. Objectives We aimed to compare 5-year outcomes of patients with severe AS and reduced LV ejection fraction (LVEF), undergoing transcatheter aortic valve replacement (TAVR) with balloon-expandable vs. self-expanding THVs. Methods In an institutional TAVR registry, patients with LVEF <50% who underwent TAVR with either balloon-expandable or self-expanding THVs were included. A 1:1 propensity-score matching was performed to account for baseline differences between groups. Results A total of 759 patients were included between August 2007 and December 2022, and propensity-score matching resulted in 134 pairs. Technical success was achieved in over 85% of patients, and was similar in both groups. Self-expanding THVs were associated with a lower mean transvalvular gradient (7.1 ± 3.7 mmHg vs. 9.9 ± 4.3 mmHg; P <0.001) and a higher incidence of ³mild-to-moderate paravalvular regurgitation (36.3% vs. 11.3%; P <0.001) compared to balloon-expandable THVs. At 5 years, patients treated with a self-expanding THV had higher all-cause mortality than those with a balloon-expandable THV (67.8% vs. 55.8%, Adjusted Hazard Ratio: 1.44; 95% CI: 1.02-2.03; P = 0.037). There were no significant differences in other clinical outcomes up to 5 years between groups. Conclusions In the setting of LV systolic dysfunction, patients treated with a self-expanding THV had higher risk of 5-year mortality compared to patients treated with a balloon-expandable THV.

Three-Year Outcomes Following TAVR in Younger (

Transcatheter aortic valve replacement (TAVR) is an alternative to surgery in patients with severe aortic stenosis, but data are limited on younger, low-risk patients. This analysis compares outcomes in low-surgical-risk patients aged <75 years receiving TAVR versus surgery. The Evolut Low Risk Trial randomized 1414 low-risk patients to treatment with a supra-annular, self-expanding TAVR or surgery. We compared rates of all-cause mortality or disabling stroke, associated clinical outcomes, and bioprosthetic valve performance at 3 years between TAVR and surgery patients aged <75 years. In patients <75 years, 352 were randomized to TAVR and 351 to surgery. Mean age was 69.1±4.0 years (minimum 51 and maximum 74); Society of Thoracic Surgeons Predicted Risk of Mortality was 1.7±0.6%. At 3 years, all-cause mortality or disabling stroke for TAVR was 5.7% and 8.0% for surgery (P=0.241). Although there was no difference between TAVR and surgery in all-cause mortality, the incidence of disabling stroke was lower with TAVR (0.6%) than surgery (2.9%; P=0.019), while surgery was associated with a lower incidence of pacemaker implantation (7.1%) compared with TAVR (21.0%; P<0.001). Valve reintervention rates (TAVR 1.5%, surgery 1.5%, P=0.962) were low in both groups. Valve performance was significantly better with TAVR than surgery with lower mean aortic gradients (P<0.001) and lower rates of severe prosthesis-patient mismatch (P<0.001). Rates of valve thrombosis and endocarditis were similar between groups. There were no significant differences in rates of residual ≥moderate paravalvular regurgitation. Low-risk patients <75 years treated with supra-annular, self-expanding TAVR had comparable 3-year all-cause mortality and lower disabling stroke compared with patients treated with surgery. There was significantly better valve performance in patients treated with TAVR. URL: https://clinicaltrials.gov; Unique identifier: NCT02701283.

Assessing post-TAVR cardiac conduction abnormalities risk using an electromechanically coupled beating heart.

Transcatheter aortic valve replacement (TAVR) has rapidly displaced surgical aortic valve replacement (SAVR). However, certain post-TAVR complications persist, with cardiac conduction abnormalities (CCA) being one of the major ones. The elevated pressure exerted by the TAVR stent onto the conduction fibers situated between the aortic annulus and the His bundle, in proximity to the atrioventricular (AV) node, may disrupt the cardiac conduction leading to the emergence of CCA. In this study, an in silico framework was developed to assess the CCA risk, incorporating the effect of a dynamic beating heart and preprocedural parameters such as implantation depth and preexisting cardiac asynchrony in the new onset of post-TAVR CCA. A self-expandable TAVR device deployment was simulated inside an electromechanically coupled beating heart model in five patient scenarios, including three implantation depths and two preexisting cardiac asynchronies: (i) a right bundle branch block (RBBB) and (ii) a left bundle branch block (LBBB). Subsequently, several biomechanical parameters were analyzed to assess the post-TAVR CCA risk. The results manifested a lower cumulative contact pressure on the conduction fibers following TAVR for aortic deployment (0.018MPa) compared to nominal condition (0.29MPa) and ventricular deployment (0.52MPa). Notably, the preexisting RBBB demonstrated a higher cumulative contact pressure (0.34MPa) compared to the nominal condition and preexisting LBBB (0.25MPa). Deeper implantation and preexisting RBBB cause higher stresses and contact pressure on the conduction fibers leading to an increased risk of post-TAVR CCA. Conversely, implantation above the MS landmark and preexisting LBBB reduces the risk.

TCT-162 Effectiveness and Safety of Self-Expanding Transcatheter Aortic Valve Replacement Compared With Balloon-Expandable Bioprosthesis: Meta-analysis and Systematic Review

TCT-162 Effectiveness and Safety of Self-Expanding Transcatheter Aortic Valve Replacement Compared With Balloon-Expandable Bioprosthesis: Meta-analysis and Systematic Review

TCT-161 Comparing the Periprocedural Outcomes of Self-Expanding Transcatheter Aortic Valve Replacement Versus Balloon-expandable Bioprosthesis: Systematic Review and Meta-Analysis

TCT-161 Comparing the Periprocedural Outcomes of Self-Expanding Transcatheter Aortic Valve Replacement Versus Balloon-expandable Bioprosthesis: Systematic Review and Meta-Analysis

Early clinical and hemodynamic outcomes of balloon-expandable versus self-expanding transcatheter aortic valve replacement in patients with large aortic annulus: a study-level meta-analysis.

This study aimed to compare early clinical and hemodynamic outcomes of transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis and large aortic annulus using either balloon-expandable valves (BEVs) or self-expanding valves (SEVs). A comprehensive search of PubMed, Scopus, and the Cochrane Central Register of Controlled Trials was conducted through September 10, 2023, to perform a meta-analysis comparing the clinical outcomes of BEV versus SEV for large aortic annulus (annulus perimeter ≥ 80mm). Seven studies (one propensity-matched study and six observational studies) met our eligibility criteria, including a total of 2167 patients (BEV, 1521; SEV, 646). The rates of procedural stroke (pooled odds ratio 0.55, 95% confidence interval 0.32-0.98), valve embolization (0.11, 0.05-0.24), need for second valve implantation (0.21, 0.17-0.26), permanent pacemaker implantation (0.43, 0.28-0.67), and aortic regurgitation ≥ moderate (0.23, 0.08-0.68) were significantly lower in the BEV group. Conversely, postoperative transvalvular gradient was significantly lower in the SEV group (pooled standard mean difference 0.55, 0.12-0.98). Subgroup analysis with newer-generation valves also showed significant differences in the need for second valve implantation and permanent pacemaker implantation, as well as aortic regurgitation ≥ moderate, favoring BEVs. BEV provides better early outcomes in TAVR for large aortic annulus in terms of lower rates of stroke, valve embolization, need for second valve, permanent pacemaker implantation, and aortic regurgitation ≥ moderate. Conversely, SEV provides a better transvalvular gradient in the early period after TAVR. The online version contains supplementary material available at 10.1007/s12055-024-01770-1.

Temporal Trends, Outcomes, and Predictors of Next-Day Discharge and Readmission Following Uncomplicated Evolut Transcatheter Aortic Valve Replacement: A Propensity Score-Matched Analysis.

Next-day discharge (NDD) outcomes following uncomplicated self-expanding transcatheter aortic valve replacement have not been studied. Here, we compare readmission rates and clinical outcomes in NDD versus non-NDD transcatheter aortic valve replacement with Evolut. Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry patients (n=29 597) undergoing elective transcatheter aortic valve replacement with self-expanding supra-annular valves (Evolut R, PRO, and PRO+) from July 2019 to June 2021 were stratified by postprocedure length of stay: ≤1 day (NDD) versus >1 day (non-NDD). Propensity score matching was used to compare risk adjusted 30-day readmission rates and 1-year outcomes in NDD versus non-NDD, and multivariable regression to determine predictors of NDD and readmission. Between the first and last calendar quarter, the rate of NDD increased from 45.4% to 62.1% and median length of stay decreased from 2 days to 1. Propensity score matching produced relatively well-matched NDD and non-NDD cohorts (n=10 549 each). After matching, NDD was associated with lower 30-day readmission rates (6.3% versus 8.4%; P<0.001) and 1-year adverse outcomes (death, 7.0% versus 9.3%; life threatening/major bleeding, 1.6% versus 3.4%; new permanent pacemaker implantation/implantable cardioverter-defibrillator, 3.6 versus 11.0%; [all P<0.001]). Predictors of NDD included non-Hispanic ethnicity, preexisting permanent pacemaker implantation/implantable cardioverter-defibrillator, and previous surgical aortic valve replacement. Most patients undergoing uncomplicated self-expanding Evolut transcatheter aortic valve replacement are discharged the next day. This study found that NDD can be predicted from baseline patient characteristics and was associated with favorable 30-day and 1-year outcomes, including low rates of permanent pacemaker implantation and readmission.

LB-9 | Self-Expanding Versus Balloon-Expandable Transcatheter Aortic Valve Replacement in Patients with Small Aortic Annuli: Additional Outcomes from the SMART Trial

LB-9 | Self-Expanding Versus Balloon-Expandable Transcatheter Aortic Valve Replacement in Patients with Small Aortic Annuli: Additional Outcomes from the SMART Trial

Self-Expanding or Balloon-Expandable TAVR in Patients with a Small Aortic Annulus

BackgroundPatients with severe aortic stenosis and a small aortic annulus are at risk for impaired valvular hemodynamic performance and associated adverse cardiovascular clinical outcomes after transcatheter aortic-valve replacement (TAVR).MethodsWe randomly assigned patients with symptomatic severe aortic stenosis and an aortic-valve annulus area of 430 mm2 or less in a 1:1 ratio to undergo TAVR with either a self-expanding supraannular valve or a balloon-expandable valve. The coprimary end points, each assessed through 12 months, were a composite of death, disabling stroke, or rehospitalization for heart failure (tested for noninferiority) and a composite end point measuring bioprosthetic-valve dysfunction (tested for superiority).ResultsA total of 716 patients were treated at 83 sites in 13 countries (mean age, 80 years; 87% women; mean Society of Thoracic Surgeons Predicted Risk of Mortality, 3.3%). The Kaplan–Meier estimate of the percentage of patients who died, had a disabling stroke, or were rehospitalized for heart failure through 12 months was 9.4% with the self-expanding valve and 10.6% with the balloon-expandable valve (difference, −1.2 percentage points; 90% confidence interval [CI], −4.9 to 2.5; P<0.001 for noninferiority). The Kaplan–Meier estimate of the percentage of patients with bioprosthetic-valve dysfunction through 12 months was 9.4% with the self-expanding valve and 41.6% with the balloon-expandable valve (difference, −32.2 percentage points; 95% CI, −38.7 to −25.6; P<0.001 for superiority). The aortic-valve mean gradient at 12 months was 7.7 mm Hg with the self-expanding valve and 15.7 mm Hg with the balloon-expandable valve, and the corresponding values for additional secondary end points through 12 months were as follows: mean effective orifice area, 1.99 cm2 and 1.50 cm2; percentage of patients with hemodynamic structural valve dysfunction, 3.5% and 32.8%; and percentage of women with bioprosthetic-valve dysfunction, 10.2% and 43.3% (all P<0.001). Moderate or severe prosthesis–patient mismatch at 30 days was found in 11.2% of the patients in the self-expanding valve group and 35.3% of those in the balloon-expandable valve group (P<0.001). Major safety end points appeared to be similar in the two groups.ConclusionsAmong patients with severe aortic stenosis and a small aortic annulus who underwent TAVR, a self-expanding supraannular valve was noninferior to a balloon-expandable valve with respect to clinical outcomes and was superior with respect to bioprosthetic-valve dysfunction through 12 months. (Funded by Medtronic; SMART ClinicalTrials.gov number, NCT04722250.)

Fish swim bladders as valve leaflets enhance the durability of transcatheter aortic valve replacement devices

Transcatheter aortic valve replacement (TAVR) has emerged as an effective therapy for inoperable patients with severe aortic stenosis (AS). However, calcification-induced limited durability restricts its application. Fish swim bladders (FSB), which are resistant to calcific degeneration, offer a viable solution to this challenge. In this study, we developed a new TAVR device using FSB as the valve leaflet. Furthermore, the in vitro durability, in vivo performance, and size selection of this TAVR device were assessed by an experimental study and finite element analysis. A self-expandable TAVR device was fabricated by suturing the FSB films into a 23 mm nitinol alloy frame. Further, hemodynamic performance, such as effective orifice area, transvalvular pressure difference and regurgitant fraction, the durability was tested by the pulsatile flow test and accelerated fatigue test, according to the ISO 5840-3. The effect of release size on hydrodynamic performance was also investigated. Finally, the in vivo performance of the TAVR device were examined using a porcine implantation model. The results showed that the strength of the FSB films satisfied the requirements for valve leaflets. The hemodynamic performance of the FSB TAVR device met the requirements of ISO 5840-3 standards. After 400 million cycles, the FSB showed no fiber loss, torn, perforation, or other valve failure phenomena. In porcine models, the devices were well-positioned, functioned well with no stenosis immediately after the operation. Collectively, we successfully developed a TAVR device with FSB as valve leaflets that exhibited good fatigue resistance. Statement of significanceThe source of material for the leaflets of commercialized biological heart valves (BHVs) is mainly bovine pericardium, but this material suffers the following problems: large and uneven thickness of the material, the presence of α-Gal and Neu5Gc antigens, and the susceptibility to structural valve degradation (SVD). New material for BHVs leaflets is rarely reported. In this study, we prepared a transcatheter aortic valve (TAV) and performed long-term in vitro and short-term in vivo studies using fish swim bladder (FSB) as the leaflets. The study confirmed that FSB TAV device can complete 400 million fatigue tests and maintain the good morphology of the leaflets, and that it still maintains good functionality after a certain amount of compression, indicating that FSB is a promising material for leaflets.

Hemodynamic performance of self-expandable transcatheter aortic valve replacement systems during valve deployment.

Little is known about valve hemodynamic performance during the Evolut and Neo deployment course. We aimed to evaluate transvalvular mean and peak-to-peak gradients over several intraprocedural timepoints during TAVR with Evolut PRO+ (Medtronic) and Neo (Boston Scientific) systems. This was single-center pilot sub-study from the SavvyWire EFficacy and SafEty in Transcatheter Aortic Valve Implantation Procedures (SAFE-TAVI) trial. Participants received either the Evolut PRO+ or Neo for native valve severe aortic stenosis and the SavvyWire (OpSens Medical) was used for device delivery, pacing, and continuous left ventricular and aortic pressure measurements. For the Evolut, evaluation was done for baseline, two-thirds of valve deployment (still recapturable), 90% of valve deployment (no longer recapturable), and post-deployment hemodynamics. For the Neo, analysis was done at baseline, after the first step (top-crown deployment), and at final status. Nineteen patients were included (Evolut = 15; Neo = 4). There were no statistically significant changes in peak-to-peak gradients (44 mm Hg [IQR:33-69] vs 43 mm Hg [IQR:26-62], P = .41) between baseline and two-thirds of valve deployment in the Evolut patients. There was a significant decrease in mean (40 mm Hg [IQR:32-54] vs 14 mm Hg [IQR:10-18], P less than .001) and peak-to-peak (43 mmHg [IQRS:26-62] vs 9 mm Hg [IQR:8-13], P less than .001) transvalvular gradients between two-thirds and 90% of valve deployment for Evolut. Neo patients exhibited a decrease in transvalvular gradients after top-crown deployment (42.5 mm Hg baseline vs 13 mm Hg). Transvalvular gradients did not vary between the point of "no-recapture" compared to baseline values in patients receiving the Evolut, whereas a significant reduction in transvalvular gradients was observed when the valve was deployed at 90% and fully deployed. The Neo valve was slightly obstructive after the first step of deployment.

Commentary: The safety and efficacy of balloon-expandable vs. self-expanding trans-catheter aortic valve replacement in high-risk patients with severe symptomatic aortic stenosis.

Commentary: The safety and efficacy of balloon-expandable vs. self-expanding trans-catheter aortic valve replacement in high-risk patients with severe symptomatic aortic stenosis.

Five-Year Follow-Up from the CoreValve Expanded Use Transcatheter Aortic Valve-in-Surgical Aortic Valve Study

Transcatheter aortic valve replacement (TAVR) provides an option for extreme-risk patients who underwent reoperation for a failed surgical aortic bioprosthesis. Long-term data on patients who underwent TAVR within a failed surgical aortic valve (TAV-in-SAV) are limited. The CoreValve Expanded Use Study evaluated patients at extreme surgical risk who underwent TAV-in-SAV. Outcomes at 5 years were analyzed by SAV failure mode (stenosis, regurgitation, or combined). Echocardiographic outcomes are site-reported. TAV-in-SAV was attempted in 226 patients with a mean age of 76.7 ± 10.8 years; 63.3% were male, the Society of Thoracic Surgeons predicted risk of mortality score was 9.0 ± 6.7%, and 87.5% had a New York Heart Association classification III or IV symptoms. Most of the failed surgical bioprostheses were stented (81.9%), with an average implant duration of 10.2 ± 4.3 years. The 5-year all-cause mortality or major stroke rate was 47.2% in all patients; 54.4% in the stenosis, 37.6% in the regurgitation, and 38.0% in the combined groups (p = 0.046). At 5 years, all-cause mortality was higher in patients with versus without 30-day severe prosthesis-patient mismatch (51.7% vs 38.3%, p = 0.026). The overall aortic valve reintervention rate was 5.9%; highest in the regurgitation group (12.6%). The mean aortic valve gradient was 14.1 ± 9.8 mm Hg and effective orifice area was 1.57 ± 0.70 at 5 years. Few patients had >mild paravalvular regurgitation at 5 years (5.5% moderate, 0.0% severe). TAV-in-SAV with supra-annular, self-expanding TAVR continues to represent a safe and lasting intermediate option for extreme-risk patients who have appropriate sizing of the preexisting failed surgical valve. Clinical and hemodynamic outcomes were stable through 5 years.

Cusp overlap method for self-expanding transcatheter aortic valve replacement.

Conduction disturbances and the need for permanent pacemaker (PPM) implantation remains a common complication for transcatheter aortic valve replacement (TAVR), particularly when self-expanding (SE) valves are used. We compared in-hospital and 30-day rates of new PPM implantation between patients undergoing TAVR with SE valves using the conventional three-cusp coplanar implantation technique and the cusp-overlap technique. We retrospectively compared patients without a pre-existing PPM who underwent a TAVR procedure with SE Evolut R or PRO valves using the cusp-overlap technique from July 2018 to September 2020 (n = 519) to patients who underwent TAVR using standard three-cusp technique from April 2016 to March 2017 (n = 128) in two high volume Canadian centers. There was no significant difference in baseline RBBB between the groups (10.4% vs. 13.2; p = 0.35). The rate of in-hospital new complete heart block (9.4% vs. 23.4%; p ≤ 0.001) and PPM implantation (8% vs. 21%; p ≤ 0.001) were significantly reduced when using the cusp-overlap technique. The incidence of new LBBB (30.4% vs. 29%; p = 0.73) was similar. At 30 days, the rates of new complete heart block (11% vs. 23%; p ≤ 0.001) and PPM implantation (10% vs. 21%, p ≤ 0.001) remained significantly lower in the cusp-overlap group, while the rate of new LBBB (35% vs. 30%; p = 0.73) was similar. Cusp-overlap approach offers several potential technical advantages compared to standard three-cusp view, and may result in lower PPM rates in TAVR with SE Evolut valve.

Comparing balloon-expandable and self-expanding transfemoral transcatheter aortic valve replacement based on subgroups in Germany 2019/2020

BackgroundPreviously, overall comparable outcomes were seen for balloon-expandable (BE) or self-expanding (SE) transfemoral transcatheter aortic valve replacement (TAVR). However, subgroup analyses based on large case numbers are still needed.MethodsGerman national data of all BE and SE transfemoral TAVR treating aortic valve stenosis in 2019 and 2020 were analysed. We then compared different outcomes and performed a subgroup analysis for the endpoint in-hospital mortality.ResultsOverall, 46,243 TAVR were analysed, 19,910 BE, and 26,333 SE. Patients in the SE group had a significantly higher logistic EuroSCORE (13.61 vs 12.66%, p < 0.001), age (81.55 vs 79.99a, p < 0.001), and proportion of women (54.82 vs 40.06%, p < 0.001). Both groups showed a similar in-hospital mortality with 2.37% in BE and 2.35% in SE (p = 0.916). In-hospital mortality also did not differ significantly after risk adjustment (OR = 0.98 [0.86, 1.13], p = 0.799). Patients in the SE group had a significantly lower risk of major bleeding (OR = 0.83 [0.73, 0.95], p = 0.006), but a significantly higher risk of stroke (OR = 1.38 [1.19, 1.59], p < 0.001), delirium (OR = 1.15 [1.06, 1.24], p = 0.001), and permanent pacemaker implantation (OR = 1.29 [1.21, 1.37], p < 0.001). In the subgroup analysis of in-hospital mortality, there were no significant differences in any of the observed subgroups (age < 75/75–79/80–84/ ≥ 85a, logistic EuroSCORE < 4/4– < 9/ ≥ 9, gender, NYHA III/IV, previous CABG, peripheral vascular disease, COPD, pulmonary hypertension, renal disease GFR < 30 ml/min, and diabetes mellitus).ConclusionIn the direct comparison of balloon-expandable and self-expanding TAVR, there are no differences for in-hospital mortality in subgroups.Graphical abstract

Self-expanding or balloon-expandable transcatheter aortic valve replacement in a German comparison

Abstract Background Studies demonstrated that results for self-expanding vs balloon-expandable transcatheter aortic valve replacement (TAVR) are similar, with larger subgroup analyzes missing. Methods We identified 46,243 self-expanding (SE) and balloon-expandable (BE) transfemoral TAVR for aortic stenosis in German hospitals in 2019 or 2020. Both in-hospital outcomes as well as subgroups for in-hospital mortality were analyzed. Results Regarding baseline characteristics, the logistic EuroSCORE was higher in SE (SE 13.6% - BE 12.7%; p&amp;lt;0.001), which also applied to age (SE 81.6a - BE 80.0a; p&amp;lt;0.001). There was a comparable in-hospital mortality rate in both groups (BE 2.37% - SE 2.35%; p=0.916). Risk adjusted in-hospital mortality was also not significantly different (OR=0.98, p=0.799). The SE group presented a significantly lower risk of major bleeding events (OR=0.83, p=0.006), however, there was a significantly higher risk of stroke (OR=1.38, p&amp;lt;0.001), risk of delirium (OR=1.15, p=0.001) as well as risk of permanent pacemaker implantation (OR=1.29, p&amp;lt;0.001). No difference has been found for acute kidney injury, mechanical ventilation &amp;gt;48h, length of hospital stay, and reimbursement. In addition, the subgroups showed no significant differences for in-hospital mortality regarding age, logistic EuroSCORE, gender, heart failure NYHA III/IV, previous coronary artery bypass graft, peripheral vascular disease, chronic obstructive pulmonary disease, pulmonary hypertension, renal disease GFR &amp;lt;30ml/min or diabetes mellitus. Conclusion Self-expanding or balloon-expandable TAVR did not show significant differences for in-hospital mortality in a subgroup analysis in Germany.

Analyzing current German transcatheter and surgical aortic valve replacement practices in pure aortic regurgitation

Abstract Background In Germany, the use of transcatheter aortic valve replacement (TAVR) for treating pure aortic regurgitation is still not regular practice. Purpose Therefore, the current development of TAVR in aortic regurgitation is to be investigated. Methods In 2018–2020, 4,025 surgical aortic valve replacements (SAVR), 50 transapical, 329 balloon-expandable transfemoral, and 457 self-expanding transfemoral TAVR in pure aortic regurgitation were studied using multivariable logistic and linear regressions. Results The TAVR groups had a higher age than SAVR (76.0-77.3a vs 62.8a) and logistic EuroSCORE (17.7-19.1 vs 4.9%). Unadjusted in-hospital mortality was highest in transapical TAVR (6.0%), followed by SAVR (5.7%), and it was lowest in transfemoral TAVR, with self-expanding procedures (2.4%) showing significantly lower in-hospital mortality than balloon-expandable (5.2%; p=0.039). After risk adjustment, we saw a significant association with lower mortality rates for balloon-expandable as well as self-expanding transfemoral TAVR vs SAVR (balloon-expandable: OR=0.50, p=0.031; self-expanding: OR=0.20, p&amp;lt;0.001). In the same way, we found that other examined outcomes were significantly in favor of TAVR: stroke (balloon-expandable: OR=0.17, p&amp;lt;0.001; self-expanding: OR=0.17, p&amp;lt;0.001), major bleeding (balloon-expandable: OR=0.04, p&amp;lt;0.001; self-expanding: OR=0.03, p&amp;lt;0.001), delirium (balloon-expandable: OR=0.19, p&amp;lt;0.001; self-expanding: OR=0.16, p&amp;lt;0.001), mechanical ventilation &amp;gt;48h (balloon-expandable: OR=0.09, p&amp;lt;0.001; self-expanding: OR=0.06, p&amp;lt;0.001), and length of hospital stay (balloon-expandable: Coefficient=-6.88d, p&amp;lt;0.001; self-expanding: Coefficient=-7.22d, p&amp;lt;0.001). Conclusion Despite lower procedure volumes in TAVR vs SAVR for pure aortic regurgitation, we see lower rates of in-hospital mortality and complications, suggesting that TAVR can be used successfully in selected patients with aortic regurgitation.

Echocardiographic and Clinical Outcomes in Symptomatic Patients With Less Than Severe Aortic Stenosis After Supra-Annular Self-Expanding Transcatheter Aortic Valve Replacement

Optimal timing for aortic valve replacement in symptomatic patients with less than severe aortic stenosis (AS) is not well defined. There is limited information on the benefit of valve replacement in these patients. Symptomatic patients with less than severe AS, defined as a mean aortic gradient ≥20 and <40mm Hg, peak aortic velocity >3 and <4m/s, and aortic valve area >1.0 and <1.5cm2, enrolled in the Society for Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy Registry and who underwent attempted supra-annular, self-expanding transcatheter aortic valve replacement (TAVR) were reviewed. Site-reported valve hemodynamics, clinical events, and quality of life metrics were analyzed at 30days and 1year after the procedure. A total of 1,067 patients with attempted TAVR (mean age 78.4 ± 8.4years; Society for Thoracic Surgery score 4.7 ± 3.4%) were found to have symptoms but less than severe AS. From baseline to postprocedure, mean gradient decreased (29.9 ± 4.9 vs 8.4 ± 4.8mm Hg, p <0.001), and aortic valve area increased (1.2 ± 0.1 vs 2.2 ± 0.7cm2, p <0.001). Clinical events included 30-day and 1-year all-cause mortality (1.5% and 9.6%), stroke (2.2% and 3.3%), and new pacemaker implantation (18.1% and 20.9%). There were statistically significant improvements in the New York Heart Association functional class and Kansas City Cardiomyopathy Questionnaire at 30days and 1year. In conclusion, patients with symptomatic but less than severe AS who underwent supra-annular, self-expanding TAVR experienced improved valve hemodynamics and quality of life measures 1year after the procedure. Randomized studies of TAVR versus a control arm in symptomatic patients with less than severe AS are ongoing.

Cusp overlap technique decreases paravalvular leakage in self-expandable transcatheter aortic valve replacement.

The cusp overlap technique allows greater visual separation between the basal annular plane and the conduction system and decreases the permanent pacemaker implantation rate. We assessed the impact of the cusp overlap technique on conduction disturbance and paravalvular leakage after transcatheter aortic valve replacement. A total of 97 patients underwent transfemoral transcatheter aortic valve replacement with self-expandable valves at our institution from November 2018 to January 2023. The mean age of the patients was 85years, and 23% were male. The patients were divided into two groups: the cusp overlap technique group and the non-cusp overlap technique group. We compared the clinical results between the two groups. The 30-day permanent pacemaker implantation rate was similar between the two groups (cusp overlap technique: 6.3% vs. non-cusp overlap technique: 10.2%, p = 0.48). The rate of new-onset conduction disturbance was slightly lower in the cusp overlap than non-cusp overlap technique group (18.8% vs. 34.7%, respectively; p = 0.08). The implanted valve function was similar between the two groups, but the rate of trivial or less paravalvular leakage (PVL) was significantly higher in the cusp overlap technique group on echocardiography (69% vs. 45%, p = 0.02). On multidetector computed tomography, the implantation depth at the membranous septum was significantly shorter in the cusp overlap technique group (2.0 ± 2.3 vs. 2.9 ± 1.5mm, p = 0.02). The degree of canting was slightly smaller in the cusp overlap technique group (1.0 ± 2.2 vs. 1.7 ± 1.9mm, p = 0.07). The relative risk of PVL equal to or greater than mild was 1.76 times higher for valve implantation without the cusp overlap technique (adjusted odds ratio, 3.74; 95% confidence interval, 1.45-9.69; p < 0.01). Transcatheter aortic valve replacement using the cusp overlap technique is associated with an optimized implantation depth, leading to fewer conduction disturbances. Optimal deployment may also maximize the radial force of self-expanding valves to reduce paravalvular leakage.

Snaring Self-Expanding Devices to Facilitate Transcatheter Aortic Valve Replacement in Patients with Complex Aortic Anatomies.

The snare-assisted technique has been described to facilitate transcatheter aortic valve replacement (TAVR) delivery system advancement in complex aortic anatomies. However, the evidence is limited to case reports. To evaluate the safety profile of the snare-facilitated approach and its impact on self-expanding (SE) TAVR outcomes, we collected consecutive patients who underwent transfemoral SE-TAVR for aortic stenosis, using propensity score matching (PSM) separately in tricuspid and type-0 and type-1 bicuspid aortic valve morphology between the snare and non-snare groups. In 766 patients, despite the snare group having significantly larger annulus angulation and maximal ascending aortic diameter, both groups achieved comparable 30-day device success rates, regardless of first-generation or new-generation valve use. After PSM, the snare group had a significantly lower new permanent pacemaker implantation rate among 193 type-0 patients (3.3% vs. 18.3%, p = 0.01). The ipsilateral group used new-generation valves less frequently (23.0% vs. 75.4%, p < 0.001), but there were no significant inter-group differences in procedure-related events, except for a lower incidence of PVL ≥ mild in the ipsilateral group (14.9% vs. 32.3%, p = 0.01). In conclusion, the snare-assisted technique appears useful in SE-TAVR with angulated aortic root anatomy, and the benefits were comparable between ipsilateral and contralateral snare techniques.