Original Title: Aortic Angulation Attenuates Procedural Success Following Self-Expandable But Not Balloon-Expandable TAVR.
Reference: Abramowitz Y et al. JACC Cardiovasc Imaging. 2016 Jul 8. [Epub ahead of print].
The angulation degree between aorta and heart can make precise valve implantation challenging, especially extreme angulation, such as a horizontal aortic root.
As obvious as it may seem, there is limited data on the impact of aortic angulation in TAVR.
The aim of this study was to assess the impact of aortic angulation immediately after transcatheter aortic valve replacement (TAVR).
The study included 582 patients undergoing TAVR that had prior procedure CT scans available for aortic angulation evaluation.
End points were considered according to the Valve Academic Research Consortium-2 definitions.
Mean aortic angulation was 47.3 ± 8.7°, and patients were divided in two groups: <48° or ≥48° angulation.
In 480 patients receiving balloon expandable valves, the aorta did not influence acute periprocedural success or short term clinical outcomes.
On the contrary, in 102 patients receiving self-expandable valves, increased aortic angulation attenuated acute periprocedural success (area under the curve: 0.73; CI 95% 0.61 to 0.85; p = 0.008).
The numerical cutoff for aortic angulation with the highest sum of sensitivity and specificity for device success was in fact ≥48° (sensitivity 85%, specificity 61%).
Patients with ≥48 angulation receiving self-expandable valves often needed a second valve and post dilation, had longer fluoroscopy time and increased device embolization and mild or greater than mild paravalvular regurgitation.
Mortality at 30 days was not influenced by device angulation.
Conclusion
Increased aortic root angulation can have a negative impact in acute periprocedural success in patients receiving self-expandable aortic valves but no in patients receiving balloon expandable valves.
Editorial Comment
Future studies with new devices should include aortic angulation as a factor to assess. New self-expandable repositionable and retrievable valves could solve this problem: during release (when presenting valve waist at annulus level) it is possible to push the whole system so that it “copies” the angulation between aorta and heart and to complete a practically horizontal release.
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