Undersizing but overfilling eliminates the gray zones of sizing for transcatheter aortic valve replacement with the balloon-expandable bioprosthesis. (October 2020)

• Record Type: Journal Article
• Authors: Patsalis, Polykarpos C.; Kloppe, Axel; Plicht, Björn; Schöne, Dominik; Schiedat, Fabian; Aweimer, Assem; Kara, Kaffer; Haldenwang, Peter Lukas; Strauch, Justus Thomas; Buck, Thomas; Mügge, Andreas
• Is Part Of: IJC heart & vasculature. Volume 30(2021)
• Publication Date: 2020-10
• Subjects: Transcatheter aortic valve replacement -- Paravalvular leak -- Aortic valve disease -- Percutaneous intervention; AR index aortic regurgitation index -- BAV balloon aortic valvuloplasty -- DAP diastolic aortic pressure -- ΔPDAP–LVEDP pressure gradient between DAP and LVEDP -- LIM principle Less Is More principle -- LVEDP left ventricular end-diastolic pressure -- NF nominal filling -- PVL paravalvular leakage -- THV transcatheter heart valve; Cardiovascular system -- Diseases -- Periodicals; Cardiovascular system -- Pathophysiology -- Periodicals; 616.1005
• DOI: 10.1016/j.ijcha.2020.100593
• Languages: English
• ISSNs: 2352-9067

Abstract

Highlights: Transcatheter heart valve size selection is still challenging. The overlap between two different prosthesis sizes for borderline annuli remains. Undersizing but overfilling improves sizing in borderline annulus cases. Undersizing but overfilling decreases the postprocedural THV-pressure gradient. Prospective studies are needed considering the TAVR expansion to younger patients. Abstract: Background: Current recommendations for valve size selection are based on multidimensional annular measurements, yet the overlap between two different transcatheter heart valve (THV) sizes remains. We sought to evaluate whether undersizing but overfilling eliminates the gray zones of valve sizing. Methods: Data of 246 consecutive patients undergoing transcatheter aortic valve replacement (TAVR) with the balloon-expandable bioprosthesis with either conventional sizing and nominal filling (group 1 (NF-TAVR), n = 154) or undersizing but overfilling under a Less Is More (LIM)-Principle (group 2 (LIM-TAVR), n = 92) were compared. Paravalvular leakage (PVL) was graded angiographically and quantitatively using invasive hemodynamics. Results: Annulus rupture (AR) occurred only in group 1 (n = 3). Due to AR adequate evaluation of PVL was possible in 152 patients of group 1. More than mild PVL was found in 13 (8.6%) patients of group 1 and 1 (1.1%) patient of group 2 (p = 0.019). Postdilatation was performed in 31 (20.1%) patients of group 1 and 6 patients (6.5%) of group 2 (p = 0.003). For patients with borderline annulus size in group 1 (n = 35, 22.7%) valve size selection was left to the physiciańs choice resulting in selection of the larger prosthesis in 10 (28.6%). In group 2 all patients with borderline annulus (n = 36, 39.1%) received the smaller prosthesis (LIM-TAVR). The postprocedural mean transvalvular pressure gradient was significantly higher in the NF-TAVR-group (11.7 ± 4 vs. 10.1 ± 3.6 mmHg, p = 0.005). Conclusion: LIM-TAVR eliminates the gray zones of sizing and associated PVL, can improve THV-performance, reduce incidence of annular rupture and simplify the procedure especially in borderline cases.