Transcatheter Aortic Valve Implantation in Patients With Severe Left Ventricular Dysfunction

Abstract

Background-Few data exist about transcatheter aortic valve implantation (TAVI) in patients with low ejection fraction.The aim of the study was to analyze safety, feasibility, and efficacy of TAVI in patients with severe left ventricular dysfunction. Methods and Results-The study sample (384 patients) was divided into 2 groups: group A (50 patients) with left ventricular ejection fraction (LVEF) Յ35%, and group B (334 patients) with LVEF Ͼ35%. Clinical, anatomic, and hemodynamic variables, as well as procedural results and follow-up outcomes, were compared between the groups. Procedural success was reached in 88%, with no significant difference between the groups. The incidence of periprosthetic leak Ͼ2ϩ/4 after TAVI was higher in group A. All other complications were similar between the 2 groups. Group A showed a significant and early improvement in LVEF (from 27.7Ϯ6.0 -35.2Ϯ11.1 after TAVI; PϽ0.0001). Thirty-day mortality was 4%; however, this was higher in group A compared with group B (10% versus 3%; Pϭ0.010). Predictors of the cumulative late mortality were congestive heart failure, logistic euroSCORE, and moderate-to-severe periprosthetic leakage after TAVI. Estimated survival by Kaplan Meier at 1 year was, respectively, 69% in group A and 87% in group B (log rank Ͻ0.0001). Conclusions-Transcatheter aortic valve implantation is a safe and effective procedure, even in patients with severe left ventricular dysfunction, leading to a high procedural success rate with an acceptable rate of complications and 30-day mortality. Also in these critically ill patients, TAVI provides clinical amelioration, with early improvement in LVEF. (Circ Cardiovasc Interv. 2012;5:253-260.)

Paravalvular Aortic Leak After Transcatheter Aortic Valve Replacement

“…14 Although the majority of post-TAVR PVL is mild (7.8-40.8%), moderate (5-37.9%) and severe (0.5-13.6%) PVL occur frequently. 1,2,6,8,10,11,13,[15][16][17][18][19][20][21][22][23][24][25][26] The largest meta-analysis of TAVR outcomes estimates the incidence of residual moderate or severe aortic regurgitation after TAVR to be 7.4%. 27 The UK TAVR registry suggests moderate-severe PVL occurred more commonly with CoreValve implants (17.3%, versus 9.6% with the Edwards implants).…”

First case reported of transcatheter aortic valve implantation in a patient affected by Fabry’s Disease and severe low-flow low-gradient aortic valve stenosis

“…Indeed, impaired LVEF (≤ 35%) does not have a negative impact on TAVI outcomes [7] , neither predicts adverse outcomes at 30-day and long-term follow-up. Of note, improvement of LVEF has been reported to be higher in patients with impaired LVEF, as compared to patients with normal pre-procedural LV function (LVEF > 35%) [8] . Furthermore, as recently reported in a substudy of the cohort A of the PARTNER trial [9] , in patients with LV dysfunction and high-surgical risk, mortality rates and LV functional recovery are comparable between TAVI and SAVR.…”

Transcatheter aortic valve replacement

“…114 In contrast, both studies observed a significant improvement in LVEF after the procedure. 113,114 In a study by van der Boon et al, survival did not differ at all between patients with normal and reduced LVEF. 115 When comparing the outcome of patients with an ejection fraction below 50% undergoing TAVR or SAVR, Clavel et al 116 observed no difference in risk-adjusted 30-day mortality, but patients undergoing TAVR had significantly better LVEF recovery.…”

“…Fraccaro et al found a significantly higher early and late mortality in patients with low LVEF. 113 Ewe et al did not note a difference in mortality, but the rate of combined major adverse events was higher in patients with an LVEF lower than 50%. 114 In contrast, both studies observed a significant improvement in LVEF after the procedure.…”

“…113,114 However, LVEF seems to improve significantly after TAVR. 113,114,116 Even though no benefit with regard to short-term mortality could be shown in comparison with SAVR, patients with low LVEF undergoing TAVR could benefit from a significantly better recovery of left-ventricular function. 47,116 valve-in-valve procedures Transcatheter heart valves have been successfully implanted in failing bioprostheses or annuloplasty rings in all valve positions.…”