Paravalvular leak vanishing at end-diastole during transcatheter aortic valve replacement

A 78-year-old man with a history of severe aortic stenosis presented with confusion, irregular behaviour and dyspnoea 8 days following transcatheter aortic valve replacement. His exam was consistent with a heart failure exacerbation and he had elevated aminotransferases, bilirubin and prothrombin time suggestive of shock liver. A CT head scan demonstrated a subacute large left temporoparietal infarction. His aminotransferase and prothrombin time levels normalised with diuresis, but his indirect bilirubin remained elevated and he developed anaemia and thrombocytopenia consistent with a haemolytic anaemia. A transthoracic echocardiogram demonstrated a paravalvular leak. His thrombocytopenia continued to worsen prompting testing for antibodies against heparin-PF4 complexes which was positive. A serotonin release assay later returned positive, confirming the diagnosis of heparin-induced thrombocytopenia. This case illustrates that the presence of haemolytic anaemia does not necessarily exclude other causes of thrombocytopenia that may occur concurrently.

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Infective Endocarditis After Surgical and Transcatheter Aortic Valve Replacement: A State of the Art Review

Journal of the American Heart Association ◽

10.1161/jaha.120.017347 ◽

2020 ◽

Vol 9 (16) ◽

Cited By ~ 1

Author(s):

Sophia L. Alexis ◽

Aaqib H. Malik ◽

Isaac George ◽

Rebecca T. Hahn ◽

Omar K. Khalique ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Prosthetic Valve Endocarditis ◽

Paravalvular Leak ◽

Surgical Aortic Valve Replacement ◽

Entry Site ◽

Transcatheter Aortic Valve ◽

Significant Difference

Abstract Prosthetic valve endocarditis (PVE) after surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) carries significant morbidity/mortality. Our review aims to compare incidence, predisposing factors, microbiology, diagnosis, management, and outcomes of PVE in surgical aortic valve replacement/TAVR patients. We searched PubMed and Embase to identify published studies from January 1, 2015 to March 13, 2020. Key words were indexed for original reports, clinical studies, and reviews. Reports were evaluated by 2 authors against a priori inclusion/exclusion criteria. Studies were included if they reported incidence and outcomes related to surgical aortic valve replacement/TAVR PVE and excluded if they were published pre‐2015 or included a small population. We followed the Cochrane methodology and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines for all stages of the design and implementation. Study quality was based on the Newcastle‐Ottawa Scale. Thirty‐three studies with 311 to 41 025 patients contained relevant information. The majority found no significant difference in incidence of surgical aortic valve replacement/TAVR PVE (reported as 0.3%–1.2% per patient‐year versus 0.6%–3.4%), but there were key differences in pathogenesis. TAVR has a specific set of infection risks related to entry site, procedure, and device, including nonstandardized protocols for infection control, valve crimping injury, paravalvular leak, neo‐leaflet stress, intact/calcified native leaflets, and intracardiac hardware. With the expansion of TAVR to lower risk and younger patients, a better understanding of pathogenesis, patient presentation, and guideline‐directed treatment is paramount. When operative intervention is necessary, mortality remains high at 20% to 30%. Unique TAVR infection risks present opportunities for PVE prevention, therefore, further investigation is imperative.

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Impact of annular and cusps calcification on occurrence of paravalvular leak after transcatheter aortic valve replacement with intra- versus supra-annular devices

European Heart Journal ◽

10.1093/ehjci/ehaa946.1968 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

I Michalowska ◽

L Kalinczuk ◽

M Dabrowski ◽

Z Chmielak ◽

K Zielinski ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Independent Effect ◽

Paravalvular Leak ◽

Transcatheter Aortic Valve ◽

Device Deployment ◽

The Impact ◽

Annular Calcification

Abstract Introduction Severe annular and valve cusps calcification is frequent among patients treated with transcatheter aortic valve replacement (TAVR). Severe annular calcification increases the risk of paravalvular leak (PVL) and was associated with worse outcomes. Whether it is accompanied by an independent effect of calcifications localized on cusps and whether the impact of cusps/annular calcification depends on supra vs intra-annular valve design is unknown. Purpose To assess the impact of cusps/annular calcifications on occurrence of moderate PVL after successful TAVR with devices of either intra- or supra-annular design. Methods 282 consecutive patients (80.3±7.6 yrs, 63% female) with baseline 384-slice CT scan were successfully treated with TAVR between Jul 2012 and Oct 2017, either with intra-annular or supra-annular devices. Severe annular calcification (clear protrusion) and severe cusps calcification (Rosenhek 4 score) were identified using a Syngo Via. Results 138 (48.9%) patients were treated with intra-annular and 144 (51.15) with supra-annular devices. Whereas severe annular calcification was similar (23.9% vs 20.1%), there was more severe cusps calcification among intra-annular valves (52.9% vs 41.7%, p=0.073). Intra-annular devices were used less frequently among bicuspid aortic valves, were also of smaller diameter, less frequently deployed after pre-dilation, and less frequently post-dilated. Post-procedure mean aortic gradient tended to be higher among intra-annular devices. Moderate PVL was less frequent among intra- vs supra-annular valves (14.5% vs 34.0%, p<0.001). However, PVL occurrence was higher (30.3%) among those (33/138, 23.9%) treated with an intra-annular valve who had severe annular calcification vs 9.5% in pts treated with an intra-annular TAVR who did not have severe annular calcification (p=0.008) unlike in patients treated with a supra-annular valve who had a high frequency of PVL with or without severe annular calcium (37.9% vs 33.0%). After excluding patients with severe annular calcium (n=62, 22%), moderate PVL was similar between those with vs without severe cusp calcification whether treated with intra- or supra-annular valves (11.8% vs 7.4% and 29.3% vs 35.1%, respectively). Combined VARC-2 safety endpoints plus 2-yr mortality occurrence were lower for intra- vs supra-annular devices (30.4% vs 43.8%, p=0.026). Conclusions Moderate PVL after intra-annular TAVR device deployment occurs in 30% of patients with protruding annular calcification. Severe cusps calcification unaccompanied by annular calcium was not associated with PVL occurrence. Higher frequency of moderate PVL (34%) seen after supra-annular valve deployment appears to be related to other parameters rather than presence of severe annular or cusps calcification. Funding Acknowledgement Type of funding source: None

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Third-Generation Balloon and Self-Expandable Valves for Aortic Stenosis in Large and Extra-Large Aortic Annuli From the TAVR-LARGE Registry

Circulation Cardiovascular Interventions ◽

10.1161/circinterventions.120.009047 ◽

2020 ◽

Vol 13 (8) ◽

Cited By ~ 2

Author(s):

Germán Armijo ◽

Gilbert H.L. Tang ◽

Nynke Kooistra ◽

Alfredo Nunes Ferreira-Neto ◽

Stefan Toggweiler ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Paravalvular Leak ◽

Third Generation ◽

Large Area ◽

Transcatheter Aortic Valve ◽

Sapien 3

Background: Currently, 2 third-generation transcatheter valves, 29-mm Sapien-3 and 34-mm Evolut-R (ER), are indicated for large sized aortic annuli. We analyzed short and 1-year performance of these valves in patients with large (area ≥575 mm 2 or perimeter ≥85 mm) and extra-large (≥683 mm 2 or ≥94.2 mm) aortic annuli undergoing transcatheter aortic valve replacement. Methods: A total of 833 patients across 12 centers with symptomatic aortic stenosis and large aortic annuli underwent transcatheter aortic valve replacement with 29-mm Sapien-3 (n=640) or 34-mm ER (n=193). Clinical, anatomic, and procedural characteristics were collected, and Valve Academic Research Consortium-2 outcomes were reported. Results: Median aortic annulus area and perimeter were 617 mm 2 (591–657) and 89.1 mm (87.0–92.1), respectively (704 mm 2 [689–743] and 96.0 mm [94.5–97.9] in the subgroup of 124 patients with extra-large annuli). Overall device success was 94.3% (Sapien-3, 95.8% and ER, 89.3%; P =0.001), with a higher rate of significant paravalvular leak ( P =0.004), second valve implantation ( P =0.013), and valve embolization ( P =0.009) in the ER group. Thirty-day and 1-year mortality was 2.4% and 9.2%, respectively, without differences between groups. Valve hemodynamics were excellent (mean gradient, 8.8±3.6 mm Hg; 3.3% rate of moderate-severe paravalvular leak) in the extra-large annulus, without differences compared with the large annulus group. Conclusions: In patients with large and extra-large aortic annuli, transcatheter aortic valve replacement using 29-mm Sapien-3 and 34-mm ER is safe and feasible. Observed differences in clinical outcomes and hemodynamic performance may guide valve choice in this cohort of patients undergoing transcatheter aortic valve replacement.

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600.08 3-Dimensional Printing Could Help Prevent Paravalvular Leak After Transcatheter Aortic Valve Replacement

JACC Cardiovascular Interventions ◽

10.1016/j.jcin.2019.01.160 ◽

2019 ◽

Vol 12 (4) ◽

pp. S44-S45

Author(s):

Chris Reiff ◽

Santiago Garcia ◽

Lars Mattison ◽

Paul Iaizzo ◽

Jorge D. Zhingre Sanchez ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Paravalvular Leak ◽

3 Dimensional ◽

Transcatheter Aortic Valve ◽

Dimensional Printing

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Use of Intracardiac Echocardiography to Differentiate Post–Transcatheter Aortic Valve Replacement Valve Insufficiency Masquerading as Paravalvular Leak

CASE ◽

10.1016/j.case.2019.11.004 ◽

2020 ◽

Vol 4 (3) ◽

pp. 111-114

Author(s):

Michael R. Bykhovsky ◽

Kimberly Atianzar ◽

Shvetank Agarwal ◽

Pushpa Shivaram ◽

Zahid Amin

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Intracardiac Echocardiography ◽

Paravalvular Leak ◽

Transcatheter Aortic Valve ◽

Valve Insufficiency

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Impact of short-term complications of transcatheter aortic valve replacement on longer-term outcomes: results from the STS/ACC Transcatheter Valve Therapy Registry

European Heart Journal - Quality of Care and Clinical Outcomes ◽

10.1093/ehjqcco/qcaa001 ◽

2020 ◽

Cited By ~ 1

Author(s):

Suzanne V Arnold ◽

Pratik Manandhar ◽

Sreekanth Vemulapalli ◽

Andrzej Kosinski ◽

Nimesh D Desai ◽

...

Keyword(s):

Health Status ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Kansas City ◽

Vascular Complication ◽

Paravalvular Leak ◽

Transcatheter Aortic Valve ◽

Increased Risk

Abstract Aims While complications of transcatheter aortic valve replacement (TAVR) have decreased, they still occur commonly and may negatively impact both short- and long-term outcomes. We sought to examine the association of complications after TAVR with survival and health status in a real-world cohort. Methods and results Among 45 884 TAVR patients from 513 US sites who survived 30 days, 21.4% had at least one major complication [stroke, bleed, vascular complication, new pacemaker, acute kidney injury (AKI), and moderate/severe paravalvular leak (PVL)]. In multivariable models, Stage 3 AKI [hazard ratio (HR) 3.43, 95% confidence interval (CI) 2.64–4.45], stroke (HR 2.62, 95% CI 2.06–3.32), and bleeding (HR 1.83, 95% CI 1.55–2.16) were independently associated with significantly increased risk of early death (<3 months) with slight attenuation in these hazards between 3 and 12 months. Moderate/severe PVL (HR 1.37, 95% CI 1.21–1.55) and new pacemaker (HR 1.15, 95% CI 1.05–1.25) were associated with more modest risk of excess mortality that was consistent through 12 months. Among surviving patients, stroke (−6.1 points, 95% CI −8.4 to −3.7), moderate/severe PVL (−3.2 points, 95% CI −4.9 to −1.6), and new pacemaker (−2.3 points, 95% CI −3.2 to −1.5) were associated with less improvement in 1-year health status, as assessed by the Kansas City Cardiomyopathy Questionnaire. Conclusion In this study of contemporary TAVR, we found that complications remain common within the first 30 days after TAVR and are associated with worse 1-year survival and health status among survivors. These findings support continued efforts to reduce major complications of TAVR and may also help define quality of care.

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