TAVR for Pure Native Aortic Valve Regurgitation

Aug 30, 2023
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Authors:
Poletti E, De Backer O, Scotti A, et al.
Citation:
Transcatheter Aortic Valve Replacement for Pure Native Aortic Valve Regurgitation: The PANTHEON International Project. JACC Cardiovasc Interv 2023;16:1974-1985.
Summary By:
Bina Ahmed, MD, FACC

Quick Takes

  • Data from the PANTHEON registry of patients undergoing TAVR using contemporary transcatheter heart valve platforms to treat pure AR showed modest technical and device success rates.
  • Risk of device embolization or migration (12.4%) and conduction deficit requiring permanent pacemaker implantation (22%) were significant without a difference between the two platforms.
  • Patients with device mobilization and migration had significantly worst 1-year outcomes.

Study Questions:

How do new-generation transcatheter heart valves (THVs) perform in patients treated for pure severe native aortic valve regurgitation (NAVR)?

Methods:

The PANTHEON (Performance of Currently Available Transcatheter Aortic Valve Platforms in Inoperable Patients With Pure Aortic Regurgitation of a Native Valve) study retrospectively included patients who underwent transcatheter aortic valve replacement (TAVR) with currently available devices (both self-expanding [SE] and balloon-expandable [BE]) for severe NAVR. Technical and device success rates as well as a composite of all-cause mortality and heart failure rehospitalization at 1 year were evaluated. The rate and clinical consequences of acute transcatheter valve embolization or migration (TVEM) were also considered.

Results:

A total of 201 patients were included. Overall technical and device success rates were 83.6% and 76.1%, respectively, and did not differ between SE and BE devices. These figures were mostly due to TVEM occurrence (14.6% vs. 16.1%, p = 0.47) and residual moderate or greater aortic regurgitation (AR) (9.2% vs. 10.1%, p = 0.87). Patients who experienced a TVEM versus non-TVEM patients had a significantly higher incidence of the composite endpoint at 1 year (25.7% vs. 15.8%, p = 0.05).

Conclusions:

Despite improved THV platforms and techniques, TAVR for pure severe NAVR remains a challenging procedure, with significant risk of TVEM. SE and BE platforms demonstrated comparable performance in this setting.

Perspective:

Unlike TAVR for aortic stenosis, use of existing THV platforms (SE or BE) for pure native aortic valve regurgitation remains without known efficacy. Current data from the PANTHEON registry of patients undergoing TAVR using contemporary THV platforms to treat pure AR showed modest technical and device success rates. Risk of device embolization or migration (12.4%) and conduction deficit requiring permanent pacemaker implantation (22%) were significant without a difference between the two platforms. Patients with device mobilization and migration had significantly worse 1-year outcomes. Off-label use of existing THV for AR needs to be considered carefully given unique anatomical features of pure native AR and device limitation of current THV platforms. Results from trials studying dedicated devices for AR will help determine the role of transcatheter therapies for AR.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease

Keywords: Aortic Valve Insufficiency, Embolization, Therapeutic, Balloon Occlusion, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Patient Readmission, Transcatheter Aortic Valve Replacement


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