Efficacy and Safety of Postdilatation to Reduce Paravalvular Regurgitation During Balloon-Expandable Transcatheter Aortic Valve Replacement

Abstract

Procedural and in-hospital outcomes for all consecutive patients treated between May 2007 and November 2011 with Edwards SAPIEN THV (Edwards Lifescience, Irvine, CA) as part of the PARTNER Background-Paravalvular regurgitation (PVR) is common after transcatheter aortic valve replacement (TAVR) and may be associated with adverse outcomes. Postdilatation (PD) has been proposed to treat PVR without being formally studied. We performed a study to evaluate the safety and efficacy of PD after balloon expandable TAVR. Methods and Results-Consecutive cases of TAVR were reviewed for clinical outcomes. Procedural transesophageal echocardiography imaging was reviewed for a subgroup of consecutive patients. PVR areas seen on a short-axis view were measured immediately after deployment, after PD, and at the completion of the study. Stent dimensions measured using angiography and the Paieon's C-THV system pre-and post-PD were compared. Between May 2007 and November 2011, 259 patients underwent TAVR at our institution. PD was performed in 106 patients (41%). These patients had larger annulus, lower cover-index; more often had transfemoral access and implantation of a 26 mm valve. There was a nonsignificant greater rate of cerebrovascular events in PD patients. There was no significant difference in major aortic injury and permanent pacemaker implantation rates between groups. TTE studies were reviewed in 58 patients (35 with PD and 23 without PD

Impact of post-dilatation on the reduction of paravalvular leak and mortality after transcatheter aortic valve implantation

“…PD has been performed due to frame under-expansion in most cases, and it was required in 22.7% of patients. This rate was quite similar to that reported in previous studies with a post-dilation rate of 30% to 38% after implantation of self-expanding prostheses and 28% to 41% for balloon-expandable valves [15,17,23,24,26]. PD might be associated with a higher rate of cardiovascular complications, conduction disturbances, annulus rupture, coronary obstruction, and cerebral embolism leading to stroke [1,4].…”

“…An impact of PVL on medium-term prognosis has recently been demonstrated also for the Edwards SAPIEN prosthesis [7]. Meta-analyses of multiple studies in the high-risk populations showed that moderate or severe PVL is an important determinant of mortality regardless of the implanted AVA -aortic valve area; CABG -coronary artery bypass graft; COPD -chronic obstructive pulmonary disease; eGFR -estimated glomerular filtration rate; IQR -interquartile range; LVEF -left ventricular ejection fraction; MI -myocardial infarction; NYHA -New York Heart Association; PCI -percutaneous coronary intervention; STS -The Society of Thoracic Surgeons; TG -transvalvular gradient valve type [24,25]. The occurrence of PVL after TAVI might be more frequent after direct valve implantation without balloon PD, resulting in more frequent PD afterwards [12].…”

Transcatheter Aortic Valve Implantation With the New Balloon-Expandable Sapien 3 Versus Sapien XT Valve System

“…Postdilatation should not be performed lightheartedly, however, because there is evidence it may lead to an increase in cerebral embolic events. 29,30 Whether it is advisable to postdilate in an attempt to further reduce mild AR to none remains to be determined.Interestingly, our matched analysis found similar pacemaker implantation rates for the S3-and SXT-THV. Preliminary S3-THV data raised concerns of an increased pacemaker dependency because the increased valve height may lead to a larger portion of the stent frame extending in the LVOT, a well-known predictor of pacemaker implantations.…”

“…Postdilatation should not be performed lightheartedly, however, because there is evidence it may lead to an increase in cerebral embolic events. 29,30 Whether it is advisable to postdilate in an attempt to further reduce mild AR to none remains to be determined.…”

Aortic Regurgitation After Transcatheter Aortic Valve Replacement

“…Correction of the device's position may be achieved by engaging one of the anchoring hooks and pulling with a snare catheter. 28 To increase the leverage effect, the snaring maneuver can be performed via transbrachial access. However, the snare technique lacks predictability and has the potential risk of THV embolization into the ascending aorta, causing vascular complications (eg, aortic dissection).…”