Transcatheter aortic valve implantation (TAVI) has become an innovative technology for the treatment of patients with severe aortic valve stenosis. Initially implemented in elderly patients with prohibitive or high surgical risk for surgical aortic valve replacement (SAVR), TAVI has subsequently expanded to increasingly younger and lower-risk populations, raising important questions regarding valve durability.
A key component of valve durability is structural valve deterioration (SVD), which involves intrinsic and structural changes in bioprosthetic leaflets, including wear, leaflet rupture, instability, fibrosis, calcification, fracture, or deformation of the stent frame, and is associated with progressive hemodynamic valve deterioration (HVD). Understanding the underlying mechanisms of valve disease is essential for patient risk stratification, implementation of appropriate therapeutic strategies, and lifelong management of younger patients. Despite its clinical relevance, limited data are available regarding predictors and prognostic correlates of this condition.
Study Characteristics: Early residual post-TAVI gradient as an independent predictor of long-term structural valve deterioration
The objective of this study was to investigate the association between early residual mean postprocedural gradient (ERMPG) after TAVI and the long-term rate of SVD, as well as the relationship between SVD, bioprosthetic valve failure (BVF), and 10-year mortality.
Both moderate and severe SVD were considered. Moderate SVD was defined as: (1) HVD showing an increase in mean aortic gradient ≥10 mmHg from hospital discharge or the 90-day echocardiographic assessment to the last available echocardiogram, with a final mean gradient ≥20 mmHg; or (2) new onset or worsening of intraprosthetic aortic regurgitation resulting in moderate or severe aortic regurgitation.
Severe SVD was defined as: (1) HVD showing an increase in mean gradient ≥20 mmHg from discharge or the 90-day echocardiogram to the last available echocardiogram, with a final mean gradient ≥30 mmHg; or (2) new onset or an increase of two or more grades of intraprosthetic aortic regurgitation resulting in severe aortic regurgitation. Another primary objective of the study was to analyze the association of SVD with BVF, all-cause mortality, and cardiovascular mortality at 10 years of follow-up.
Between September 2007 and December 2014, a total of 1,291 patients undergoing TAVI with CoreValve/Evolut valves met the inclusion criteria. After a median follow-up of 59.4 months, 46 patients developed SVD, corresponding to a cumulative incidence of 3.6%. A significant and progressive increase in SVD risk was observed across ERMPG tertiles (p = 0.009), and in multivariable analysis, ERMPG emerged as an independent predictor of SVD (HR 1.05; 95% confidence interval [CI]: 1.01–1.08; p = 0.004).
Among the 46 patients with SVD, 25 (54.3%) experienced or developed BVF. Furthermore, SVD was associated with higher 10-year rates of all-cause mortality (HR 2.12; 95% CI: 1.49–3.00; p < 0.001) and cardiovascular mortality (HR 5.78; 95% CI: 2.63–12.71; p < 0.001) compared with patients without SVD.
Conclusion: Impact of structural valve deterioration after TAVI on bioprosthetic valve failure and 10-year mortality
In patients with severe aortic valve stenosis undergoing TAVI with the CoreValve/Evolut system, ERMPG was independently associated with the long-term development of SVD. The presence of SVD, defined by serial changes in Doppler-derived mean gradients or the occurrence of intraprosthetic aortic regurgitation, was linked to a greater than 50% risk of BVF. Moreover, these patients exhibited higher rates of all-cause and cardiovascular mortality compared with those without SVD.
Original Title: Predictors of long-term structural valve deterioration and failure after transcatheter aortic valve implantation.
Reference: EuroIntervention 2026;22:e90-e100 • Tullio Palmerini et al.
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