Transcatheter aortic valve replacement (TAVR) has widely demonstrated its significant benefits, both in high-risk and inoperable patients, as well as in those with intermediate and low risk.
While paravalvular regurgitation has been a challenge, its management has improved with operator experience and a deeper understanding of CT angiographies. However, in cases of regurgitation, elevated gradient, or lack of valve expansion, balloon post-dilation (BPD) is the usual solution, even though it has been potentially linked to future valve deterioration, structural failure, stroke, or ring rupture.
Despite numerous analyses, this association has not been demonstrated in the short term. One study addressed this issue by analyzing 1835 patients who underwent TAVR with CoreValve and Evolut R. In it, 417 (22.7%) underwent BPD. The long-term follow-up assessed structural valve dysfunction (SVD) according to VARC-3 criteria.
The average patient age was 82 years, and there was a higher prevalence of men among those who received BPD. The STS Score indicated a 6-% mortality rate, and 80% of patients had hypertension. 31% had diabetes, 21% experienced severe renal function impairment, 27% had peripheral disease, 21% had chronic obstructive pulmonary disease (COPD), 21% had atrial fibrillation, 18% had experienced a heart attack, 15% underwent myocardial revascularization surgery, 29% underwent percutaneous coronary implantation, 10% had complete left bundle branch block, and 7% had complete right bundle branch block. Ejection fraction was 51%, with a mean gradient of 52 mmHg.
Read also: Events According to Revascularization Modality in the ISCHEMIA Trial.
Transfemoral access was the most frequent access (82%), followed by subclavian and aortic access. Pre-dilation was more frequent in those who did not receive BPD (84.3% vs. 71.4%, p<0.0001), and the most implanted valves were 26 and 29, followed by 31 and 23.
At 6 years of follow-up, there were no significant differences in all-cause mortality (51%), cardiovascular mortality (14%), heart attack (2.7%), stroke/transient ischemic attack (6.3%), need for pacemaker (31%), aortic surgery (0.6%), endocarditis (0.4%), and valve thrombosis (0.2%). There were also no differences in small-vessel disease (1.4% vs. 2.1%, p=0.381), nor in mean gradient or presence of paravalvular regurgitation.
Conclusion
Post-dilation after TAVR in self-expanding valves does not appear to be associated with an increased risk of adverse clinical events or structural deterioration over 6 years of follow-up.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Reference: Jorge Sanz Sánchez, et al. Catheter Cardiovasc Interv. 2024;103:209–218.
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