Balloon vs Self-Expandable Valves in TAVI With Increased Aortic Angulation

Increased aortic root angulation adversely influenced acute procedural success after self-expandable transcatheter aortic valve implantation (TAVI), but not after balloon-expandable TAVI, suggesting that balloon-expandable valves may be preferred in this patient population.

Yigal Abramowitz, MD, of The Heart Institute at Cedars-Sinai Medical Center in Los Angeles, and colleagues evaluated 582 patients who underwent TAVI at the Institute with contrast CT available to analyze aortic angulation. Their findings were published in JACC: Cardiovascular Imaging.

Researchers divided patients into 2 groups—one group for patients with aortic angulation <480 and another for those with aortic angulation ≥480. Overall, the mean angulation of the aorta was 47.3 ± 8.70. Researchers measured TAVI end points, device success, and adverse events to evaluate the impact of increased aortic angulation on acute procedural success after TAVI.

“In the present study we found that aortic root angulation does not influence the short term clinical outcome following balloon expandable TAVI,” the authors wrote.

“All measures of short term procedural success including device success, need for second valve or postdilatation, PVR [paravalvular regurgitation] rates, major complications, and mortality were similar between the 2 aortic angulation groups. The relatively short valve stent frame and the flexibility of the delivery system are the main factors that have contributed to these results.”

Among the 480 patients who underwent balloon-expandable TAVI, aortic angulation did not influence procedural success or the patients’ short-term clinical outcome. However, increased aortic angulation significantly attenuated procedural success among the 102 patients who underwent self-expandable TAVI (AUC: 0.73; 95% confidence interval: 0.61-0.85; P=.008).

Researchers noted that the numerical cut-off for aortic angulation with the highest sum of sensitivity and specificity for device success was ≥480 (sensitivity 85%, specificity 61%). Aortic angulation ≥480 was associated with increased need for second valve postdilatation, increased fluoroscopy time, increased valve embolization, and increased postprocedural paravalvular regurgitation.

In addition, rates of major complications after 30 days and 6-month mortality were similar between both aortic angulation groups.

The results demonstrated an independent significant correlation between increased aortic angulation and reduced device success in patients who underwent self-expandable TAVI. However, the reduced device success did not result in a significant increase in short-term mortality or complications following self-expandable TAVI.

“Future studies with larger number of patients, longer follow up and use of different valve types including re-positional self-expanding devices may further clarify this subject,” the authors wrote. “Randomized trial with both BE [balloon expandable] or SE [self expandable] valve for patients with increased AA [aortic angulation] may also better evaluate the effect of aortic root angulation on the clinical outcome following TAVI.”

Disclosures: Dr Makkar received grant support from Edwards Lifesciences Corporation and St. Jude Medical; is a consultant for Abbott Vascular, Cordis, and Medtronic; and holds equity in Entourage Medical. Dr Jilaihawi is a consultant for Edwards Lifesciences Corporation, St. Jude Medical, and Venus MedTech.

Reference

Abramowitz Y, Maeno Y, Chakravarty T, et al. Aortic angulation attenuates procedural success following self-expandable but not balloon expandable transcatheter aortic valve implantation. JACC Cardiovasc Imag. 2016. doi: 10.1016/j.jcmg.2016.02.030.