Residuelle paravalvuläre Prothesenleckage nach TAVI – prognostisch relevant?

Abstract

The occurrence of paravalvular leakages (PVL) after transcatheter aortic valve implantation (TAVI) is frequent, and more than mild PVL have been associated with increased in-hospital mortality and an unfavorable long-term outcome. The higher incidence of PVL after TAVI than after surgical aortic valve replacement obviously relates to the different procedures. With TAVI, the calcified native leaflets are crushed against the aortic anulus during implantation, possibly preventing adequate stent-frame expansion and thus causing PVL. Possible prosthesis/aortic anulus discongruence due to indirect anulus sizing and limited prosthesis sizes available play also an important role. The TAVI operator is often faced with the problem whether or not PVL should be corrected immediately, e.g. by postdilatation, snaring or valve-in-valve implantation. Recently proposed quantitative evaluation of PVL by use of the aortic regurgitation index (ARI), the transaortic pressure gradient ∆PDAP–LVEDP and the myocardial supply-demand ratio (DPTI/SPTI) can facilitate on-table decision making. Upgraded multi-modality imaging by use of 3D-echocardiography and multi-detector computed tomography but also „balloon-sizing“ in cases with borderline anulus sizes may improve valve size selection and thus reduce PVL. In addition, next-generation devices offer dedicated PVL-solutions. This article gives an overview about the grading of PVL after TAVI, its incidence and prognostic impact and reduction strategies.

Kernaussagen

• Die residuelle paravalvuläre Prothesenleckage (PVL) nach TAVI wird mit einer Häufigkeit von bis zu 80 % beobachtet. Eine mehr als milde PVL tritt dabei in 10 – 20 % der Fälle auf und ist mit einer erhöhten Sterblichkeit assoziiert.

• Für die PVL-Beurteilung werden in der Regel die Echokardiografie, die Angiografie nach den Sellers-Kriterien und invasive hämodynamische Parameter wie der „aortic regurgitation index“, der ∆P_{DAP – LVEDP} und der „myocardial supply demand ratio“ eingesetzt, für die in Bezug auf die prognostische Relevanz bestimmte Grenzwerte definiert werden konnten. Diese Grenzwerte (ARI < 25, ∆P_{DAP – LVEDP} ≤ 18 mmHg, „myocardio supply demand ratio“ ≤ 0,7) erlauben es, während der Prozedur die Notwendigkeit weiterer interventioneller Maßnahmen wie Nachdilatation der Prothese, „Snaring“ oder Valve-in-Valve-Implantationen abzuwägen, um das Interventionsergebnis hinsichtlich einer PVL zu optimieren.

• Mittels dreidimensionaler Bildgebung ist es möglich, die häufig nicht zirkuläre Anatomie des Aortenklappenanulus zu erfassen und somit die Limitationen einer einzigen, zweidimensionalen Messung im transösophagealen Langachsenschnitt zu überkommen. Folgende Anulus-Parameter werden bestimmt: minimaler und maximaler Durchmesser, Perimeter und Fläche.

• Im Falle einer grenzwertigen Anulusgröße, bei der die Auswahl zwischen 2 Prothesengrößen der subjektiven Einschätzung des Interventionalisten obliegt, kann ein Ballon-Sizing die Entscheidung erleichtern.

• Die Reduktion der PVL bleibt eine aktuelle Herausforderung, insbesondere auch in Anbetracht einer möglichen Ausweitung der TAVI-Indikation auf Patienten mit einem nur moderat erhöhten Risiko für eine chirurgische Therapie. Neben einem verbesserten Screening und verbesserter Implantationstechniken sind auch technische Weiterentwicklungen nötig.

• Literatur

• 1 Leon MB, Smith CR, Mack M et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010; 363: 1597-1607
• 2 Smith CR, Leon MB, Mack MJ et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011; 364: 2187-2198
• 3 Sinning JM, Hammerstingl C, Vasa-Nicotera M et al. Aortic regurgitation index defines severity of peri-prosthetic regurgitation and predicts outcome in patients after transcatheter aortic valve implantation. J Am Coll Cardiol 2012; 59: 1134-1141
• 4 Patsalis PC, Konorza TFM, Al-Rashid F et al. Incidence, Outcome and Correlates of Residual Paravalvular Aortic Regurgitation after Transcatheter Aortic Valve Implantation and Importance of Hemodynamic Assessment. EuroIntervention 2013; 8: 1398-1406
• 5 Tamburino C, Capodanno D, Ramondo A et al. Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis. Circulation 2011; 123: 299-308
• 6 Abdel-Wahab M, Zahn R, Horack M et al. Aortic regurgitation after transcatheter aortic valve implantation: incidence and early outcome. Results from the german transcatheter aortic valve interventions registry. Heart 2011; 97: 899-906
• 7 Kodali SK, Williams MR, Smith CR et al. Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement. NEJM 2012; 366: 1686-1695
• 8 Thourani VH, Ailawadi G, Szeto WY et al. Outcomes of surgical aortic valve replacement in high-risk patients: a multiinstitutional study. Ann Thorac Surg 2011; 91: 49-55
• 9 Edmunds LH Jr, Clark RE, Cohn LH et al. Guidelines for reporting morbidity and mortality after cardiac valvular operations. J Thorac Cardiovasc Surg 1996; 112: 708-711
• 10 Vahanian A, Alfieri O, Al-Attar N et al. Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2008; 29: 1463-1470
• 11 Patsalis PC, Konorza TFM, Al-Rashid F et al. Hemodynamic Assessment of Residual Paravalvular Aortic Regurgitation (PAR) after TAVI: Impact of Myocardial Supply-Demand Ratio (DPTI: SPTI) on Survival. Am J Physiol Heart Circ Physiol 2013; 304: H1023-1028
• 12 Détaint D, Lepage L, Himbert D et al. Determinants of significant paravalvular regurgitation after transcatheter aortic valve implantation: impact of device and annulus discongruence. J Am Coll Cardiol Cardiovasc Interv 2009; 2: 821-827
• 13 Willson AB, Webb JG, Labounty TM et al. 3-Dimensional aortic annular assessment by multidetector computed tomography predicts moderate or severe paravalvular regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol 2012; 59: 1287-1294
• 14 Jilaihawi H, Kashif M, Fontana G et al. Cross-sectional computed tomographic assessment improves accuracy of aortic annular sizing for transcatheter aortic valve replacement and reduces the incidence of paravalvular aortic regurgitation. J Am Coll Cardiol 2012; 59: 1275-1286
• 15 Messika-Zeitoun D, Serfaty JM, Brochet E et al. Multimodal assessment of the aortic an-nulus diameter: implications for transcatheter aortic valve implantation. J Am Coll Cardiol 2010; 55: 186-194
• 16 Kappetein AP, Head SJ, Généreux P et al. Updated Standardized Endpoint Definitions for Transcatheter Aortic Valve Implantation. The Valve Academic Research Consortium-2 Consensus Document. . J Am Coll Cardiol 2012; 60: 1438-1454
• 17 Vahanian A, Baumgartner H, Bax J et al. Guidelines on the management of valvular heart disease: The task force on the management of valvular heart disease of the European Society of Cardiology. Eur Heart J 2007; 28: 230-268
• 18 Sinning JM, Vasa-Nicotera M, Chin D et al. Evaluation and management of paravalvular aortic regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol 2013; 62: 11-20
• 19 Sellers RD, Levy MJ, Amplatz K et al. Left retrograde cardioangiography in acquired cardiac disease: technic, indications and interpretations in 700 cases. Am J Cardiol 1964; 14: 437-447
• 20 Hayashida K, Lefèvre T, Chevalier B et al. Impact of post-procedural aortic regurgitation on mortality after transcatheter aortic valve implantation. JACC Cardiovasc Interv 2012; 5: 1247-1256
• 21 Gotzmann M, Korten M, Bojara W et al. Long-term outcome of patients with moderate and severe prosthetic aortic valve regurgitation after transcatheter aortic valve implantation. Am J Cardiol 2012; 110: 1500-1506
• 22 Oliveros RA, Boucher CA, Groves BM et al. Myocardial supply-demand ratio in aortic regurgitation. Chest 1979; 76: 50-55
• 23 Uhl GS, Boucher CA, Oliveros RA et al. Exercise-induced myocardial oxygen supply-demand imbalance in asymptomatic or mildly symptomatic aortic regurgitation. Chest 1981; 80: 686-691
• 24 Hoffman JI, Buckberg GD. The myocardial supply-demand ratio: a critical review. Am J Cardiol 1978; 41: 327-333
• 25 Vincent WR, Buckberg GD, Hoffman JI. Left ventricular subendocardial ischemia in severe valvar and supravalvar aortic stenosis. A common mechanism. . Circulation 1974; 49: 326-333
• 26 Moat NE, Ludman P, de Belder MA et al. Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis: the UK. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry. J Am Coll Cardiol 2011; 58: 2130-2138
• 27 Gilard M, Eltchaninoff H, Iung B et al. FRANCE 2 Investigators. Registry of transcatheter aortic-valve implantation in high-risk patients. . N Engl J Med 2012; 366: 1705-1715
• 28 Hamm CW, Möllmann H, Holzhey D et al. for the GARY-Executive Board. The German Aortic Valve Registry (GARY): in-hospital outcome. Eur Heart J 2013; Epub ahead of print
• 29 Buellesfeld L, Grube E. A permanent solution for a temporary problem. J Am Coll Cardiol Intv 2012; 5: 578-581
• 30 Koos R, Mahnken AH, Dohmen G et al. Association of aortic valve calcification severity with the degree of aortic regurgitation after transcatheter aortic valve implantation. Int J Cardiol 2011; 150: 142-145
• 31 Himbert D, Pontnau F, Messika-Zeitoun D et al. Feasibility and outcomes of transcatheter aortic valve implantation in high-risk patients with stenotic bicuspid aortic valves. Am J Cardiol 2012; 110: 877-883
• 32 Takagi K, Latib A, Al-Lamee R et al. Predictors of moderate-tosevere paravalvular aortic regurgitation immediately after CoreValve implantation and the impact of postdilatation. Catheter Cardiovasc Interv 2011; 78: 432-443
• 33 Schultz C, Rossi A, van Mieghem N et al. Aortic annulus dimensions and leaflet calcification from contrast MSCT predict the need for balloon post-dilatation after TAVI with the Medtronic CoreValve prosthesis. EuroIntervention 2011; 7: 564-572
• 34 Ussia GP, Barbanti M, Ramondo A et al. The valve-in-valve technique for treatment of aortic bioprosthesis malposition. J Am Coll Cardiol 2011; 57: 1062-1068
• 35 Nombela-Franco L, Rodés-Cabau J, DeLarochellière R et al. Predictive factors, efficacy, and safety of balloon post-dilation after transcatheter aortic valve implantation with a balloon-expandable valve. J Am Coll Cardiol Intv 2012; 5: 499-512
• 36 Eggebrecht H, Doss M, Schmermund A et al. Interventional options for severe aortic regurgitation after transcatheter aortic valve implantation: balloons, snares, valve-invalve. Clin Res Cardiol 2012; 101: 503-507
• 37 Webb JG, Binder RK. Post-dilating transcatheter heart valves. J Am Coll Cardiol Intv 2012; 5: 513-514
• 38 Toggweiler S, Wood DA, Rodés-Cabau J et al. Transcatheter valve-in-valve implantation for failed balloon-expandable transcatheter aortic valves. J Am Coll Cardiol Intv 2012; 5: 571-577
• 39 Vavuranakis M, Vrachatis D, Stefanadis C. CoreValve aortic bioprosthesis: repositioning techniques. JACC CardiovascInterv 2010; 3: 565-566
• 40 Majunke N, Doss M, Steinberg DH et al. How should I treat a misplaced self-expanding aortic bioprosthetic valve?. EuroIntervention 2010; 6: 537-542
• 41 Zahn R, Schiele R, Kilkowski C et al. Correction of aortic regurgitation after transcatheter aortic valve implantation of the Medtronic CoreValveTM prosthesis due to a too-low implantation, using transcatheter repositioning. J Heart Valve Dis 2011; 20: 64-69
• 42 Piazza N, De Jaegere P, Schultz C et al. Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve. Circ CardiovascInterv 2008; 1: 74-81
• 43 Willson AB, Webb JG, LaBounty TM et al. 3-dimensional aortic annular assessment by multidetector computed tomography predicts moderate or severe paravalvular regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol 2012; 59: 1287-1294
• 44 Kasel AM, Cassese S, Bleiziffer S et al. Standardized imaging for aortic annular sizing: implications for transcatheter valve selection. JACC Cardiovasc Imaging 2013; 6: 249-262
• 45 Patsalis PC, Al-Rashid F, Neumann T et al. Preparatory balloon aortic valvuloplasty during transcatheter aortic valve implantation for improved valve sizing. JACC Cardiovasc Interv 2013; 6: 965-971