Undersizing but overfilling eliminates the gray zones of sizing for transcatheter aortic valve replacement with the balloon-expandable bioprosthesis

Polykarpos C Patsalis; Axel Kloppe; Björn Plicht; Dominik Schöne; Fabian Schiedat; Assem Aweimer; Kaffer Kara; Peter Lukas Haldenwang; Justus Thomas Strauch; Thomas Buck; Andreas Mügge

doi:10.1016/j.ijcha.2020.100593

Undersizing but overfilling eliminates the gray zones of sizing for transcatheter aortic valve replacement with the balloon-expandable bioprosthesis

Int J Cardiol Heart Vasc. 2020 Jul 30:30:100593. doi: 10.1016/j.ijcha.2020.100593. eCollection 2020 Oct.

Affiliations

¹ Department of Cardiology and Angiology, University Hospital Bergmannsheil, Ruhr University Bochum, Germany.
² Department of Cardiology, Klinikum Westfalen, Heart Center Westfalen, Dortmund, Germany.
³ Department of Cardiology, Agaplesion General Hospital Hagen, Germany.
⁴ Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr University Bochum, Germany.

Abstract

Background: Current recommendations for valve size selection are based on multidimensional annular measurements, yet the overlap between two different transcatheter heart valve (THV) sizes remains. We sought to evaluate whether undersizing but overfilling eliminates the gray zones of valve sizing.

Methods: Data of 246 consecutive patients undergoing transcatheter aortic valve replacement (TAVR) with the balloon-expandable bioprosthesis with either conventional sizing and nominal filling (group 1 (NF-TAVR), n = 154) or undersizing but overfilling under a Less Is More (LIM)-Principle (group 2 (LIM-TAVR), n = 92) were compared. Paravalvular leakage (PVL) was graded angiographically and quantitatively using invasive hemodynamics.

Results: Annulus rupture (AR) occurred only in group 1 (n = 3). Due to AR adequate evaluation of PVL was possible in 152 patients of group 1. More than mild PVL was found in 13 (8.6%) patients of group 1 and 1 (1.1%) patient of group 2 (p = 0.019). Postdilatation was performed in 31 (20.1%) patients of group 1 and 6 patients (6.5%) of group 2 (p = 0.003). For patients with borderline annulus size in group 1 (n = 35, 22.7%) valve size selection was left to the physiciańs choice resulting in selection of the larger prosthesis in 10 (28.6%). In group 2 all patients with borderline annulus (n = 36, 39.1%) received the smaller prosthesis (LIM-TAVR). The postprocedural mean transvalvular pressure gradient was significantly higher in the NF-TAVR-group (11.7 ± 4 vs. 10.1 ± 3.6 mmHg, p = 0.005).

Conclusion: LIM-TAVR eliminates the gray zones of sizing and associated PVL, can improve THV-performance, reduce incidence of annular rupture and simplify the procedure especially in borderline cases.

Keywords: AR index, aortic regurgitation index; Aortic valve disease; BAV, balloon aortic valvuloplasty; DAP, diastolic aortic pressure; LIM principle, Less Is More principle; LVEDP, left ventricular end-diastolic pressure; NF, nominal filling; PVL, paravalvular leakage; Paravalvular leak; Percutaneous intervention; THV, transcatheter heart valve; Transcatheter aortic valve replacement; ΔPDAP–LVEDP, pressure gradient between DAP and LVEDP.