Original title: Determinats and Outcomes of Acute transcatheter Valve-in Valve Therapy or Embolization. Reference: Raj R Makkar, et al. J Am Coll Cardiol 2013;62:418-30
Percutaneous aortic valve implantation has proven to be feasible, safe and a successful follow up. Only in a few patients is the two-valve implantation necessary due to bad positioning or embolism but the evolution of these patients has not been studied. In the PARTNER study, (Placement of Aortic Transcatheter Valve Trial Edwards SAPIEN Trans-catheter Heart Valve), 2,554 patients were included. 63 (2.5%) required a second valve implantation within the first (TV-in-TV) and with 26 (1%) embolization occurred (TVE). The valve used in all cases was the Edwards SAPIEN (Edwards Lifesciences, LLC, Irvine, California).
Within the number of patients requiring TV-in TV, 56 were due to severe aortic regurgitation not only because of the bad position of the valve but also for dysfunction of the leaflets. The following served as independent predictors of a second valve; male sex, prior myocardial revascularization surgery, low ejection fraction and moderate to severe mitral regurgitation. Both at 30 days and 12 months, these patients had higher mortality, cardiac mortality, permanent pacemaker and re-hospitalization. TVE was also more frequent immediately after implantation in men with low gradient and a larger aortic annulus. Fourteen were resolved by a percutaneous approach and twelve by surgery. Conversion to surgery had a higher mortality, (33.3% versus 14.3%). Both at 30 days and 12 months the patients with valve embolization had significantly higher mortality, cardiac mortality, stroke and increased vascular and bleeding complications. Both complications required hemodynamic support, more contrast and exposure time to radiation.
Conclusion:
Device embolization or the need to implant a second valve into the first are both serious TVAR complications that often require multiple valves. This can be caused by both anatomical and technical factors and implies an increase in mortality, which is very important to the proper planning of the procedure.
Comment:
The proper planning of the procedure is important, taking into account both the anatomical characteristics of the patient and the experience of the surgeons. These two complications are associated with increased mortality and surgery conversion, besides renal aggression due to contrast, greater exposure to rays and hospitalization.
Courtesy of Carlos Fava MD,
Interventional Cardiologist.
Favaloro Foundation. Buenos Aires. Argentina.
Dr. Carlos Fava para SOLACI.ORG
