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TAVR research should focus on preventing embolization, dislocation
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Researchers of a meta-analysis concluded that future research into transcatheter aortic valve replacement should not only focus on miniaturization and improving flexibility of the delivery systems, but also on modifications to prevent embolization or dislocation of the valve.
The conclusion was based on rates of emergent cardiac surgery (ECS) after TAVR, which, although low, was the most common cause of embolization or dislocation of the prosthesis and was further associated with a mortality rate of two-thirds by 30 days in study results published in EuroIntervention.
The literature search found 46 studies comprising 9,251 patients undergoing transfemoral, transapical or trans-subclavian TAVR for severe symptomatic aortic valve (AV) stenosis published between 2004 and November 2011. Of these patients, 102 required ECS. Reasons why were included for 88 patients (86%). Of the 88 reasons, 36 (41%) were performed for embolization or dislocation of the AV prosthesis, with aortic dissection (n=14), coronary obstruction (n=5), severe AV regurgitation (n=10), annular rupture (n=6), aortic injury (n=14) and myocardial injury including tamponade (n=12) comprising the rest of the group.
Thirty-day mortality rates were “bleak,” the researchers concluded, being about ninefold higher (67.1 ± 37.9% vs. 7.5 ± 4%) in patients who needed ECS compared with those who did not.
“Given that the majority of ECS were performed for device embolization or migration, technical improvements for preventing this during deployment, ie, development of retrievable, re-positionable TAVR prostheses, as well as for facilitating easy retrieval of malpositioned or embolized devices, may have significant potential for reducing ECS,” they wrote. Although also calling for better use of imaging to minimize malposition and embolization, the researchers said “miniaturization and improved flexibility of the delivery systems and/or devices may also help reduce ECS for complications such as aortic rupture or dissection.”
Disclosure: Eggebrecht is a clinical proctor for Edwards Lifesciences and Medtronic and has received honoraria payments.
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