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TAVR led to encouraging clinical outcomes in bicuspid aortic valve disease
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Transcatheter aortic valve replacement yielded encouraging clinical outcomes at 30 days and 1 year in a cohort of patients with bicuspid aortic valve disease.
Researchers conducted a retrospective analysis of the TAV-in-BAV Registry to assess clinical outcomes after TAVR in 139 elderly patients with bicuspid aortic valve disease. The mean age of the patients was 78 years and the mean Society of Thoracic Surgeons predicted risk of mortality score was 4.9%. The researchers collected baseline and procedural data along with follow-up results from patients who underwent TAVR at 12 centers in Europe and Canada from April 2005 to January 2014. The balloon-expandable transcatheter heart valve (Sapien XT, Edwards Lifesciences) was used in 48 patients and the self-expandable transcatheter heart valve (CoreValve, Medtronic) was used in 91 patients.
Bicuspid aortic valve stenosis was reported in 65.5% of patients, mixed disease in 33.8% and regurgitation in 0.7%, according to the results. Among those with a confirmed bicuspid aortic valve type, 68.3% were type 1, 26.7% were type 0 and 5% were type 2.
Sixty-three percent of patients had multislice CT-based transcatheter aortic valve sizing; this approach was utilized in 77.1% of patients who received the balloon-expandable transcatheter heart valve and 56% who received the self-expandable transcatheter heart valve (P=.02).
Procedure-associated mortality was 3.6%. Transcatheter aortic valve embolization occurred in 2.2%. Conversion to surgery was required by 2.2% of patients.
Postprocedural echocardiography findings demonstrated a decrease in mean aortic gradient of 48.7 ± 16.5 mm Hg to 11.4 ± 9.9 mm Hg (P<.0001). Post-implantation aortic regurgitation grade ≥2 was reported in 28.4% of patients overall (92% paravalvular), with 19.6% in the balloon-expandable transcatheter heart valve group and 32.2% in the self-expandable transcatheter heart valve group (P=.11). Aortic regurgitation grade ≥2 outcome was prevalent in just 17.4% of patients who underwent multislice CT-based transcatheter aortic valve sizing (16.7% in the balloon-expandable transcatheter heart valve group and 17.6% in the self-expandable transcatheter heart valve group; P=.99). Multivariate analysis indicated an association between multislice CT-based transcatheter aortic valve sizing and reduced aortic regurgitation (OR=0.19; 95% CI, 0.08-0.45).
“A high incidence of post-implantation aortic regurgitation is observed following [TAVR in patients with bicuspid valve disease]. The incidence of post-implantation paravalvular leak is moderated by [multislice CT-based transcatheter aortic valve sizing], which should be considered mandatory for [TAVR in patients with bicuspid valve disease],” the researchers wrote.
At 30 days, device safety was reported in 79.1% of patients, device success in 89.9% and device efficacy in 84.9%. At 1 year, the mortality rate was 17.5%. The researchers observed an association between major vascular complications and increased mortality at 1 year (OR=5.66; 95% CI, 1.21-26.43).
“Longer-term follow-up of a larger cohort of patients is required to more completely assess the efficacy and durability of [TAVR] in patients with bicuspid disease,” the researchers wrote.
Disclosure: Some researchers report associations with companies that include Biotronik, Boston Scientific, DirectFlow, Edwards Lifesciences, General Electric and Medtronic.
Perspective
Back to TopSamir Kapadia, MD
One of the take-home messages from this study is that in patients with bicuspid valves, putting in a transcatheter valve may not be as predictable as in patients with otherwise symmetrical tricuspid aortic valves. A second message is that when the replacement valve was sized appropriately with a CT scan, the leak was less. While the researchers did mention that sizing is not a panacea, and I agree, appropriate sizing and placement of the transcatheter valve appears to be very important in these patients. A third message is that understanding the mechanism of aortic regurgitation may give us more insight into what exactly needs to be done to improve either the devices or the procedure. I think the conclusion is kind of sobering. I would caution that you have to be more experienced and more deliberate, and understand the anatomy very well before you do such a procedure in these patients.
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