Transcatheter aortic valve implantation: Do leaks matter?

Abstract

Key Points• Transcatheter aortic valve implantation (TAVI) has become more prevalent and is now performed in moderate-and low-surgical-risk patients.• Moderate-to-severe postoperative aortic regurgitation (AR) confers greater mortality risk and worse cardiovascular outcomes.• Mild postoperative AR confers higher heart failure readmission rates without affecting mortality.Transcatheter aortic valve implantation (TAVI) initially targeted highrisk or inoperable patients. With time, the indications started involving low-and moderate-risk patients. Several studies showed that postoperative aortic regurgitation (AR) increased mortality and conferred worse outcomes. 1 As the technology improved, some new devices incorporated paravalvular skirts to decrease the risk of paravalvular leak. However, these improvements did not get rid of mild paravalvular AR, which remains prevalent. This highlights the importance of assessing the impact of mild postoperative paravalvular AR on cardiovascular outcomes and mortality. Yoshijima et al 2 studied 1,572 patients who were enrolled in the Optimized transCathEter vAlvular Intervention (OCEAN-TAVI) registry from 2013 to 2016, which involved 14 collaborating hospitals in Japan. The prospective OCEAN-TAVI trial compared the Sapien XT/S3 (Edwards Lifesciences, Irvine, California) and the Medtronic CoreValve System (Medtronic, Minneapolis, Minnesota) for the treatment of severe aortic stenosis. After a median followup of 213 days, there were no significant differences in the mortality rate, but there was a significantly higher rate of heart failure (HF) readmissions in the mild post-AR (aortic regurgitation) group than in the none-to-trace post-AR group. Significant predictors of HF readmission included mild post-AR, mild pre-AR, mild pre-MR (mitral regurgitation), and eGFR <60 ml/min/1.62 m 2 . Mild post-AR's effect on HF readmissions was augmented in patients with ejection fraction (EF) <50%, less pre-AR than post-AR, or concentric left ventricular hypertrophy. This study came in the wake of conflicting data regarding the impact of mild post-AR on mortality in a world where TAVI has become a preferred procedure for intermediate-and highsurgical-risk patients. As physicians move more toward performing TAVI in low-risk patients, it becomes even more important to understand the impact of mild post-AR, which remains more prevalent than higher degrees of post-AR. Limitations of this study included using echocardiographic criteria developed for native valve disease, shadowing with the transcatheter valves, and lack of echocardiographic core lab adjudication.Of note, certain studies 3 looked at the prevalence of preprocedure AR and found that it did not affect outcomes; rather, it was postprocedural AR that had the major impact. This applies to patients whose primary indication for surgery is severe aortic stenosis. However, the study by Yoshijima et al, 2 likewise shows the importance of postoperative AR as compared to preoperative AR as an important predictor of outcomes.What makes sense is ...