TAVR in Aortic Regurgitation

Study Questions:

What is the safety and efficacy of transcatheter aortic valve replacement (TAVR) in pure native aortic regurgitation (AR)?

Methods:

This study examined 331 patients with symptomatic severe native AR treated with TAVR and enrolled in a multicenter registry, and compared procedural success and outcomes between earlier and newer generations of devices, and examined predictors of adverse events in the overall cohort.

Results:

In patients treated with newer (n = 212) versus earlier (n = 119) TAVR devices, there were no significant differences in mean Society of Thoracic Surgeons (STS) score (6.2 ± 6.7 vs. 7.6 ± 6.7; p = 0.08). Newer generations of devices (vs. earlier) were associated with less use of transfemoral access (60.8% vs. 87.4%, p < 0.001) and had higher reported success rates (81.1% vs. 61.3%, p < 0.001), with lower rates of ≥ moderate aortic regurgitation (4.2% vs. 18.8%, p < 0.001) and use of second valve implantation (12.7% vs. 24.4%, p = 0.007). There were no differences in unadjusted 30-day outcomes between groups, including all-cause mortality. The rates of all-cause and cardiovascular death at 1 year were 24.1% and 15.6%, respectively. In the overall group, predictors of all-cause mortality on multivariable analysis included ≥ moderate post-TAVR AR (hazard ratio [HR], 2.85; 95% confidence interval [CI], 1.52-5.35; p = 0.001), ≥ moderate mitral regurgitation at baseline (HR, 2.11; 95% CI, 1.29-3.45; p = 0.003), ejection fraction ≤45% (HR, 1.78; 95% CI, 1.07-2.94; p = 0.03), and STS score (1.03, 95% CI, 1.00-1.06; p = 0.04).

Conclusions:

TAVR using newer generations of devices has increased procedural success in patients with severe native AR. Moderate or greater aortic regurgitation following the procedure is independently associated with increased mortality.

Perspective:

This registry study observed a relatively high procedural success rate and a relatively low rate of cardiovascular death in selected patients undergoing TAVR for severe native AR. Newer devices had significantly higher success rates, with markedly lower rates of significant AR and need for second valve implantation. These improvements likely represent improved valve design and procedural techniques, and much of this difference was driven by changes between the older CoreValve device and the newer Evolut R device. The presence of ≥ moderate post-TAVR AR was the only procedure-related predictor of mortality identified in this study, and remains an important target for further improvement. This study is limited by potential selection bias, and future randomized trials are needed to assess the safety and efficacy of TAVR in native AR.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Aortic Valve Insufficiency, Cardiac Surgical Procedures, Heart Valve Diseases, Heart Valve Prosthesis Implantation, Mitral Valve Insufficiency, Outcome Assessment (Health Care), Stroke Volume, Transcatheter Aortic Valve Replacement


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