Post-dilation in TAVI associated to more stroke and more paravalvular regurgitation

Courtesy of Dr. Carlos Fava.

Moderate/severe paravalvular regurgitation (PVR) after TAVR is present in 10%-14% of all cases, according to different series. The treatment of choice is post-dilation, generally effective in most cases. However, this strategy carries a risk of stroke. The true impact of this conduct is still unclear.

This review analyzed 6 studies that included 5007 patients; 889 of them underwent post-dilation (17.8%). The remaining 4118 patients did not undergo post-dilation (82.2%).

Populations were similar, but the group undergoing post-dilation (PD) included more male patients, presented a higher rate of coronary disease, and more frequent presence of New York Heart Association functional class III/IV. No differences were observed as regards EuroSCORE_log or ejection fraction.

Also read: “TAVI Without Predilation Is Feasible and Safe”

At 30 days, there were no differences in mortality (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 0.88-1.74; p = 0.22) and acute myocardial infarction (OR: 0.93; 95% CI: 0.46-1.9; p = 0.85). However, the PD group tended to require definitive pacemaker implantation more frequently (OR: 1.28; 95% CI: 0.99-1.67; p = 0.06) and presented higher rates of moderate/severe PVR.

In 81% of all cases, PD reduced PVR by at least one grade. The rate of regurgitation remained high in patients who did not undergo PD.

At 1-year follow-up, there were no differences as regards mortality (OR: 0.98; 95% CI: 0.61-1.56; p = 0.92); however, among the PD group the prevalence of stroke was higher (10.2% vs. 2.6%; p = 0.0031) and PVR rates continued to be higher (OR: 3.64; 95% CI: 1.96-6.75; p < 0.001).

Conclusion

PD significantly improves the rate of PVR. However, careful patient selection is needed to minimize increased risk of stroke.

Editorial Comment

The presence of calcium at valve level is one of the greatest challenges for TAVR, and the association between higher-than-mild PVR and worse outcomes is well-known.

The rates of coronary or peripheral disease are associated with patients with more comorbidities and valvular calcification. This must be taken into account when deciding on the characteristics of the valve to be implanted.

PD has emerged as the strategy of choice for the reduction of PVR, at the cost of higher stroke rates.

Correct valvular assessment through an angioTAC and adequate implantation valve selection is of the utmost importance.

Second-generation valves have reduced the presence of PVR. The future will surely bring about much improvement in that sense.

Courtesy of Dr. Carlos Fava.

Original title: Post-Dilation in Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

Reference: Nelson Wang, et al. Journal of Interventional Cardiology 2017;30:204-211.

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