TAVR Post-dilation Is Safe

Courtesy of Dr. Carlos Fava.

Numerous studies have shown that the presence of aortic regurgitation after TAVR is associated with worse evolution, and that balloon post-dilation (BPD) is the adequate strategy to correct this. However, a few reports using first generation valves have associated BPD to complications such as stroke, annulus rupture and valve displacement, (among others).

The study looked at 1616 patients from the PARTNER 2 and SAPIENS 3 trials; 208 of these patients received BPD (12.5%).

Baseline characteristics were similar, except patients receiving BPD had higher STS score (7.2 vs. 6.4 p=0.0008), less lung capacity, a history of immunosuppression, atrial fibrillation and more eccentric annular valve. In addition, there was less oversizing and more subvalvular calcification, though with no difference in annulus calcification.

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After TAVR, BPD favored a larger aortic valve area (1.72± 0.41 cm2 vs. 1.66±0.37 cm2; p = 0.04). There was no mismatch or transvalvular aortic regurgitation, but there was more paravalvular regurgitation.

At 30 day follow-up, there were no differences in death or stroke.

At one year, there were no differences in mortality, cardiac mortality, stroke or rehospitalization, but there was higher presence of minor stroke, and percutaneous valve reintervention.

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Predictors of BPD need were the use of immunosuppressors, moderate to severe sub-annular calcification, and oversizing, given the valve’s elliptical quality.

Conclusion

BPD is more frequently used in patients with low oversizing and severe calcification. BPD was not associated with procedural complications or an increase of fatal major events and rehospitalization at one year follow up.

Comment

This analysis of two large studies show us that BPD is feasible and safe and that it improves evolution, since it reduces the presence of severe leak.

It is important to properly assess calcium burden and oversizing in trying to reduce paravalvular leak and the need of BPD.

Though there were no more major strokes, there was a high rate of minor stroke and most likely more micro embolisms in patients undergoing BPD. Cerebral protection devices might be useful in this sense.

Courtesy of Dr. Carlos Fava.

Original title: The Effect of Post-Dilatation on Outcomes in the PARTNER 2 SAPIEN 3 Registry.

Reference: Rebecca T. Hahn, et al. J Am Coll Cardiol Intv 2018;11:1710–8

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