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Treating patients with excessively large annuli with self-expanding transcatheter aortic valves: insights into supra-annular structures that anchor the prosthesis

Behandlung von Patienten mit extrem großen Anuli mittels selbstexpandierender Transkatheter-Aortenklappen: Einblicke in supraanuläre prothesenverankernde Strukturen

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Abstract

Background

Some patients referred for transcatheter aortic valve replacement (TAVR) have excessively large annuli (ELA) without device options according to current sizing charts. This retrospective study aims to summarize the presentation and outcomes of ELA patients receiving first-generation self-expanding valves.

Methods

The TAVR database was reviewed in search for cases of self-expanding valves. Patients who had annuli exceeding the perimeter limit on the device sizing chart were referred to as the ELA group. Patients who had annuli within the range covered by the two largest sizes and received the corresponding valve size served as the control group (CG). Baseline, procedures, outcomes, and imaging characteristics on multislice computed tomography (MSCT), such as native anatomy and postimplant stent geometry, were compared.

Results

A total of 28 patients were included in the ELA group and 82 in the CG. The patients in the ELA group were younger than those in the CG (72.5 ± 6.2 vs. 75.4 ± 5.8 years, P = 0.03). The median intended perimeter oversizing in relation to the annulus in the ELA group was much smaller than in the CG (−0.4 [−4.6, 4.1] % vs. 16.1 [11.7, 20.8] %, P < 0.01). The calcium burden in the aortic root was around 1.3-fold greater in the ELA group than the CG (756.0 [534.5, 1670.9] vs. 582.1 [310.3, 870.9] mm3, P = 0.01). The need for second valve implantation was higher in ELA (21.4% vs. 12.2%, P = 0.23) but no valve embolization was encountered. The 1‑year follow-up was comparable, including >mild paravalvular leak.

Conclusion

Under cautious patient selection using MSCT, TAVR with self-expanding valves in patients with ELA appears feasible. Supra-annular structures likely provide the extra anchoring.

Zusammenfassung

Hintergrund

Einige Patienten, die einen transkathetergestützten Aortenklappenersatz (TAVR) erhielten, haben gemäß den aktuellen Größentabellen extrem große Anuli (ELA) ohne Geräteoptionen. Diese retrospektive Studie soll die Präsentation und die Ergebnisse von ELA-Patienten zusammenfassen, die selbstexpandierende Herzklappen der ersten Generation erhalten haben.

Methoden

Für die Suche nach Fällen von selbstexpandierenden Herzklappen wurde die TAVR-Datenbank überprüft. Patienten, bei denen die Anuli die Perimetergrenze auf der Größentabelle des Geräts überschritten, wurden der ELA-Gruppe zugeteilt. Patienten, deren Anuli innerhalb des von den beiden größten Größen abgedeckten Bereichs lagen und welche die entsprechende Klappengröße erhielten, wurden der Kontrollgruppe (CG) zugewiesen. Baseline, Verfahren, Ergebnisse und Bildgebungscharakteristika der Mehrschicht-Computertomographie (MSCT), wie die native Anatomie und die Geometrie nach Implantation des Stents, wurden verglichen.

Ergebnisse

Insgesamt wurden 28 Patienten in die ELA-Gruppe und 82 in die CG aufgenommen. Die Patienten in der ELA-Gruppe waren jünger als die in der CG (72,5 ± 6,2 vs. 75,4 ± 5,8 Jahre; p = 0,03). Die mittlere beabsichtigte Überdimensionierung des Perimeters im Verhältnis zum Anulus war in der ELA-Gruppe deutlich kleiner als in der CG (−0,4 [−4,6–4,1] % vs. 16,1 [11,7–20,8] %; p < 0,01). Die Kalziumbelastung in der Aortenwurzel war in der ELA-Gruppe etwa 1,3-mal höher als in der CG (756,0 [534,5–1670,9] vs. 582,1 [310,3–870,9] mm3; p = 0,01). Die Notwendigkeit einer zweiten Klappenimplantation war in der ELA-Gruppe höher (21,4% vs. 12,2%; p = 0,23), aber es wurde keine Klappenembolisation festgestellt. Das 1‑Jahres-Follow-up war vergleichbar, einschließlich eines >milden paravalvulären Lecks.

Schlussfolgerung

Bei vorsichtiger Patientenauswahl mittels MSCT erscheint eine TAVR mit selbstexpandierenden Klappen bei Patienten mit ELA machbar. Die supraanulären Strukturen bieten wahrscheinlich die zusätzliche Verankerung.

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Funding

This work was supported by the National Natural Science Foundation of China (81970325); the 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University; and Science and Technology Support Plan of Sichuan Province (2017JY0330 and 2018SZ0172).

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Authors and Affiliations

  1. Department of Cardiology, West China Hospital, Sichuan University, #37 Guo Xue Alley, 610041, Chengdu, China

    Tian-Yuan Xiong MD, PhD, Yan-Biao Liao MD, Yi-Jian Li MD, Fei Chen MD, Yuanweixiang Ou MD, Xi Wang MD, Zi-Jie Wang MD, Xi Li MD, Zhen-Gang Zhao MD, Yuan Feng MD & Mao Chen MD, PhD

  2. Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China

    Wei Meng MD

Authors
  1. Tian-Yuan Xiong MD, PhD
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  2. Yan-Biao Liao MD
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  11. Yuan Feng MD
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Contributions

MC and YF conceived and designed research. YJL, YO, ZJW, XW, XL, and YF collected raw data and performed follow-ups. YBL and FC analyzed data. TYX and YLB wrote the manuscript. WM and ZGZ made critical revision suggestions to the manuscript. All authors read and approved the manuscript.

Corresponding author

Correspondence to Mao Chen MD, PhD.

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Conflict of interest

T.-Y. Xiong, Y.-B. Liao, Y.-J. Li, F. Chen, Y. Ou, X. Wang, Z.-J. Wang, X. Li, Z.-G. Zhao and W. Meng declare that they have no competing interests. Y. Feng and M. Chen are consultants/proctors of Venus MedTech and MicroPort.

The study was approved by the Research Ethics Board of West China Hospital. Written informed consent was obtained from all study participants.

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The data are available from the corresponding author on reasonable request.

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Xiong, TY., Liao, YB., Li, YJ. et al. Treating patients with excessively large annuli with self-expanding transcatheter aortic valves: insights into supra-annular structures that anchor the prosthesis. Herz 46 (Suppl 2), 166–172 (2021). https://doi.org/10.1007/s00059-020-04973-5

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