TAVI POUR TOUS SANS COMPROMIS - PR CHRISTIAN SPAULDING DÉPARTEMENT DE CARDIOLOGIE HÔPITAL EUROPÉEN GEORGES POMPIDOU PARIS - High Tech Cardio
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TAVI POUR TOUS SANS COMPROMIS
Sans compromis sur les fuites paravalvulaires : un grade 2, c’est trop !
PR CHRISTIAN SPAULDING
DÉPARTEMENT DE CARDIOLOGIE
HÔPITAL EUROPÉEN GEORGES
POMPIDOU PARIS
Conflits d’intérêt Consultant: Techwald, Medtronic, Edwards Honoraires: Zoll, Abbott, Astra-Zeneca, Boehringer Ingelheim, BMS
Impact of paravalvular regurgitation on the mid-term
outcome after transcatheter and surgical aortic valve
replacement
This multicentre study showed that both mild and
moderate-to-severe PVR were independent predictors of
worse survival after TAVI.
Mild and moderate-to-severe PVR are not frequent after
SAVR, but tend to decrease survival also in these patients.
Laakso T. et al. Impact of paravalvular regurgitation on the mid-term outcome after transcatheter and surgical aortic
valve replacement.
Eur J Cardiothorac Surg. 2020 Dec 1;58(6):1145-1152.
IA Post-TAVI et Mortalité
Kodali S et al, European Heart Journal 2015; 36, 449–456
Fréquence IA post-TAVI
Traces à minime (traces to mild): 40-67%
Modérée à importante (moderate to severe): 4 à 20%
Webb JG et al Circulation 2007;116:755– 63.
Walther T et al.Circulation 2007; 116:I240 –5.
De Jaegere PP et al EuroIntervention 2008;4:351–7
Takagi H et al Int I Cardiol 2016
SAPIEN 3 PVL ≥ 2+ rate / + moderate rate SAPIEN 3 goes along with a PVL≥2+ rate in the range of 2,2%, weighted average
Paravalvular Leak: SAPIEN 3 Consistently low
over time
p=0,85 p=0,89
Fernandez-Santos et al analysed a subset of SAPIEN 3
recipients from the SOURCE 3 registry (n = 276)
Echocardiography was performed at baseline, post-procedure,
and at 1 year, including assessment of GLS (Global Longitudinal
Strain) using standard two-dimensional images, and core
laboratory analysis.
Paired analyses between baseline and discharge, baseline and
at 1 year were conducted
Hemodynamic parameters were improved after TAVI and
sustained to 1 year.
At 1 year, the rate of moderate to severe paravalvular leaks
(PVL) was 1.8%
The discharge GLS (–15.6 ± 5.1; p = 0.004; n = 149) improved
significantly from baseline (–15.1 ± 4.8) following TAVI.
This improvement was sustained at 1 year compared with
baseline (–17.0 ± 4.6, p < 0.001; n = 100).
Total Aortic Regurgitation Paravalvular Regurgitation
Fernandez-Santos S et al. Valve hemodynamic performance and myocardial strain after
implantation of a third-generation, balloon-expandable, transcatheter aortic valve. Cardiol
J. 2019 May 20
SURTAVI: Aortic regurgitation
PVL ≥ 2+ / ≥ moderate rate in RCT, Registry, Propensity Matched Studies and CE Mark in next generation devices Balloon expandable valves, SAPIEN 3 / SAPIEN 3 Ultra, show very low PVL ≥ 2+ rate whereas self expandable valve go along with higher rates Lotus Portico Evolut R /PRO SAPIEN 3 / 3 Ultra Acurate NEO
Paravalvular Leak : SAPIEN 3 vs. Evolut R vs.
Acurate NEO in a propensity matched study
PSAPIENS 3 Ultra and paravalvular leak
Fuites paravalvulaires post-TAVI : Facteurs
favorisants et prevention
Valve sous-taillée
Qualité scanner, calcul « collégiale »
Mauvaise positiondeuxième
Repositionnement, de la valve
valve ?
Mauvaise
Choix de la apposition de la valve: calcifications
valve, post-dilatation?Paravalvular Leak: Impact of Calcification
Severity of landing zone with Evolut R / PRO
Patients who underwent TAVR with the
CoreValve Evolut R or PRO (n=381) from
September 2015 to March 2018 were divided
by aortic valve calcification extent. Patients
with SC aortic valve anatomy (n=98; men,
>2,062 and women, >1,377 Agatston units)
were compared with those with non-severely
calcified (NCS) aortic valve anatomy after 1:2
propensity score matching
Moderate AR was present in 3.1% of SC
patients and in 0.5% of NSC patients
Piayda K et al. Performance of the CoreValve Evolut R and PRO in Severely Calcified Anatomy: A Propensity Score
Matched Analysis. Heart Lung Circ . 2020 Jun 16;S1443-9506
14Paravalvular Leak: Impact of Calcification Severity of
landing zone with SAPIEN 3
Aortic valve calcification severity has been
associated with higher rates of aortic
regurgitation (AR) following TAVR.
Guimarães et al analysed in a multicenter study
including 626 SAPIEN 3 recipients the impact of
severe calcification. 1 group had a high index
calcium score (iCS) (HCS, iCS ≥ median), and
the other a low iCS (LCS, iCS < median).
The mean CS was 3758 ± 1417 AU and 1616 ±
691 AU in the HCS and LCS groups, respectively
(p < 0.001). The incidence of moderate-severe
AR post-TAVR was low in both groups
(HCS:1.6%,LCS:1.6%, p = 1.0), and valve
gradient and area were similar between groups.
Guimarães L et al. Transcatheter aortic valve replacement with the balloon-expandable SAPIEN 3 valve: Impact of calcium score on valve performance and clinical outcomes.
Int J Cardiol . 2020 May 1;306:20-24IA Post-TAVI : le problème des définitions
Kappelstein PA et al, VARC 2 consensus document, JTCS 2013
Limitation techniques
Reproductible ?
3, 4, 5, 7 grades ?IA Post-TAVI: Evaluation en pratique
Une évaluation parfois subjective…
Conclusions: Fuites para-valvulaires post-TAVI
Augmente la mortalité à long terme
Nette diminution des fuites para-valvulaires avec valves de nouvelle génération
Fréquence fuites para-valvulaires > 2+: 2,2% avec Sapiens 3
Facteurs favorisants: mauvaise position valve, valve trop petite, calcifications
Prévention et traitement per-procédure:
- Préparation procédure: Lecture « collégiale » du scanner
- Position valve: incidence, repositionnement, (deuxième valve)
- Calcifications : choix de la valveUne jupe et encore plus…
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