• SCAI TAVR Center
    Supported by:Medtronic

    June 2015 Journal Scan

    Presented by Kreton Mavromatis, MD, FSCAI

    Incidence and predictors of debris embolizing to the brain during transcatheter aortic valve implantation

    Van Mieghem NM, El Faquir N, Rahhab Z, Rodríguez-Olivares R, Wilschut J, Ouhlous M, Galema TW, Geleijnse ML, Kappetein AP, Schipper ME, de Jaegere PP.
    JACC Cardiovasc Interv. 2015 Apr 27;8(5):718-24

    • Authors' Conclusion: “Debris is captured with filter-based embolic protection in the vast majority of patients undergoing TAVR. Tissue-derived material is found in 63% of cases and is more frequent with the use of balloon-expandable systems and more oversizing.” 

    A prospective randomized evaluation of the TriGuard™ HDH embolic DEFLECTion device during transcatheter aortic valve implantation: results from the DEFLECT III trial.

    Lansky AJ, Schofer J, Tchetche D, Stella P, Pietras CG, Parise H, Abrams K, Forrest JK, Cleman M, Reinöhl J, Cuisset T, Blackman D, Bolotin G, Spitzer S, Kappert U, Gilard M, Modine T, Hildick-Smith D, Haude M, Margolis P, Brickman AM, Voros S, Baumbach A.
    Eur Heart J. 2015 May 19.

    • Authors' Conclusion: ‘TriGuard cerebral protection during TAVI is safe and complete cerebral vessel coverage was achieved in 89% of subjects. In this exploratory study, subjects undergoing protected TAVI had more freedom from ischaemic brain lesions, fewer neurologic deficits, and improved cognitive function in some domains at discharge and 30 days compared with controls.”

    • Interpretation: The above two studies emphasize 1) the still underappreciated potential effects of the TAVR procedure on the cerebral function due to embolization and 2) the promise of cerebral protection devices in improving the safety of TAVR (and perhaps other intravascular procedures). 

     

    Treatment of acquired von Willebrand syndrome in aortic stenosis with transcatheter aortic valve replacement.

    Spangenberg T, Budde U, Schewel D, Frerker C, Thielsen T, Kuck KH, Schäfer U.
    JACC Cardiovasc Interv. 2015 Apr 27;8(5):692-700

    • Authors' Conclusion: “Abnormal von Willibrand multimers (AbM) in patients with AS undergoing TAVR is frequent. However, TAVR is capable of correcting AbM and therefore possibly acquired Von Willibrand syndrome in patients with AS. As opposed to SAVR, bleeding and transfusion requirement in TAVR patients was not associated with severe high molecular weight multimer (HMWM) deficiency; patient prosthesis mismatch was rare and HMWM were uninfluenced by the procedure. Aortic regurgitation after TAVR adversely influenced HMWM recovery.”

    • Interpretation: One of the most problematic morbidities due to AS is recurrent GI bleeding, thought to be due (at least in part) to acquired von Willibrand Syndrome. This study shows that successful TAVR has the potential to reverse von Willibrand syndrome. Clinical data on the effect of TAVR on GI bleeding is now needed.

     

    Long-term outcomes of percutaneous paravalvular regurgitation closure after transcatheter aortic valve replacement: a multicenter experience.

    Saia F, Martinez C, Gafoor S, Singh V, Ciuca C, Hofmann I, Marrozzini C, Tan J, Webb J, Sievert H, Marzocchi A, O'Neill WW.
    JACC Cardiovasc Interv. 2015 Apr 27;8(5):681-8.

    • Authors' Conclusion: “Transcatheter closure of PVR after TAVR can be performed with a high procedural success rate; however, the long-term mortality remains high mainly due to noncardiac causes”

    • Interpretation: This international, multicenter registry validates a one “weapon” we have to fight paravalvular regurgitation, namely percutaneous closure with an Amplatzer Vascular Plug. However, the high mortality despite the high and durable procedural success also brings into question how much of the relationship between paravalvular leak and mortality is cause-and-effect vs. paravalvular leak being a marker of higher risk.

     

    Long-term outcomes after transcatheter aortic valve replacement in high-risk patients with severe aortic stenosis: the u.k. Transcatheter aortic valve implantation registry.

    Duncan A, Ludman P, Banya W, Cunningham D, Marlee D, Davies S, Mullen M, Kovac J, Spyt T, Moat N.
    JACC Cardiovasc Interv. 2015 Apr 27;8(5):645-53.

    • Authors' Conclusion: “In the large U.K. Transcatheter Aortic Valve Implantation Registry, long-term outcomes after TAVR are favorable with 3- and 5-year survival rates of 61.2% and 45.5%, respectively. Long-term survival after TAVR is largely determined by intrinsic patient factors. Other than stroke, procedural variables, including paravalvular aortic leak, did not appear to be independent predictors of long-term survival.”

    • Interpretation: This study produces some of the longest follow-up data on “real world” patients undergoing TAVR to date. They mortality data support the use of the procedure in high-operative risk patients, but expectations in patients with collections of comorbidities--including renal insufficiency, chronic lung disease, atrial fibrillation, LVEF < 30%--should be tempered.

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