Evolut Self-Expanding Transcatheter Aortic Valve Replacement in Patients with Extremely Horizontal Aorta (Aortic Root Angle ≥ 70°)

Abstract

Because of its rigidity and non-steerability, the presence of a horizontal aortic root poses a major anatomical issue during transcatheter aortic valve replacement (TAVR) with Evolut self-expanding valve. Previous studies have elucidated the difficulties of coaxial implantation of the self-expanding valve in patients with horizontal aorta, often resulting in increased complications and a lower device success rate. To date, most patients with extremely horizontal aorta (aortic root angle !70°) have been excluded from major TAVR clinical trials. Therefore, available data on TAVR with Evolut in this challenging anatomy are limited, and standardized treatment strategies and clinical results remain unknown. Herein, we report a clinical case series of TAVR with Evolut in extremely horizontal aorta. Among seven patients (aged 80-92 years; STS score, 12.6% ± 7.9%) who underwent TAVR with Evolut system, aortic root angle ranged from 71°to 83°(mean, 75.1°± 4.5°). All patients achieved device success with dedicated strategies and were clinically stable at 3-month follow-up. None of the patients had more than mild paravalvular leakage (PVL) at any point during follow-up.Complications in three patients included complete atrioventricular block requiring a permanent pacemaker implantation, cerebral infarction because of atrial fibrillation 3 days after TAVR, and cardiac tamponade requiring pericardiocentesis. In this case series, Evolut self-expanding TAVR in extremely horizontal aorta was effective and feasible with a high device success rate. Based on anatomical features, some dedicated strategies majorly contribute to the success of this procedure. Large-scale multicenter studies are required to confirm our findings.

Time Course and Risk Factors of New-Onset Complete Atrioventricular Block After Transcatheter Aortic Valve Implantation

“…Predictors of CAVB after TAVI were reported to include the occurrence of baseline conduction abnormalities, use of self-expanding valves, great implantation depths, and a large oversizing index. 18,22,23) However, baseline RBBB was not a significant predictor of CAVB or PPM implantation in our study. This may be explained by the relatively small number of subjects with RBBB (5.8%) in our patient population.…”

Self‐expanding transcatheter aortic valve replacement in patients with extremely horizontal aortas

“…According to previous studies, the AA thresholds of 48°and 51°have been used to illustrate increased angulation, which is associated with worse clinical outcomes in self-expanding TAVR, such as a lower device success rate and more paravalvular leakage, stroke, and vascular complications. 5,15,16 However, except for sporadic case series reporting a few successful cases, 17 no evidence of TAVR exists in patients with extremely horizontal aortas (AA ≥ 70°). Thus, the study was performed to evaluate the feasibility of self-expanding TAVR for AS patients with extremely horizontal aortas.…”

The Effect of Aortic Angulation on Clinical Outcomes of Patients Undergoing Transcatheter Aortic Valve Replacement

“…TAVR with self-expandable (SE) valves has been shown to be effective in treating severe aortic stenosis (AS) with fewer long-term complications, including relatively less annular rupture, vascular complications, and paravalvular leak (PVL) [ 4 ] . However, the presence of a horizontally oriented aortic root during TAVR with the SE Evolut™ R valve may pose challenges due to its rigidity and lack of orientability [ 4 ] . Therefore, a thorough analysis of the aortic valvular complex and multislice computed tomography (MSCT) before the procedure is crucial for patients undergoing SE Evolut™ R TAVR [ 5 ] .…”