Moderate or severe paravalvular leak (PVL) following transcatheter aortic valve replacement (TAVR) remains a considerable problem for clinicians all over the world. What do we know about this common complication—and what do we still need to learn?
A team of specialists aimed to learn as much as they could about this topic, performing a systematic review of all the research and data related to post-TAVR PVL that they could find. The researchers shared their findings in Current Problems in Cardiology.
“Previous reports suggested that mild PVR is commonly observed after TAVR and usually leads to a benign outcome,” wrote lead author Sandeep Bhushan, PhD, from the department of cardiothoracic surgery at Chengdu Second People’s Hospital in China, and colleagues. “However, other studies showed that patients with PVL had an increased late mortality.”
The group examined hundreds of abstracts and studies, eventually landing on 30 different analyses to include in their review. Overall, they found, PVL rates ranged from just 7% to 40%.
PVL’s impact on clinical outcomes, the authors wrote, remains unclear. One meta-analysis of 17 different studies found that post-TAVR PVL “was associated with a two-fold increase in overall all-cause mortality.” More research is still needed, however, before final conclusions can be made.
Reviewing their large collection of data, Bhushan et al. noted that aortic root calcification volume, larger annulus dimensions and pre-TAVR transvalvular peak velocity could all be used to predict when post-TAVR PVL may be an issue. Calcification volume, they emphasized, stands out as an “independent predictor of PVL.”
“Several non-anatomical factors that have not been evaluated thoroughly includes the high baseline transaortic pressure gradient, baseline aortic regurgitation, reduced left ventricular ejection fraction, NYHA functional class and peripheral vascular disease,” the group added.
The analysis also included a look at ways PVL can be treated; many of those strategies involved medical imaging.
“Multi-slice CT and echocardiography before the procedure along with integrated angiography with echocardiography during the procedure are crucial to ensure implanting the right devise type with the right size to the right patient in the right position,” the authors wrote. “The optimal projection and implantation angles for transcatheter heart valve positioning and deployment should be chosen based on multimodality imaging to ensure ideal positioning with less rate of PVL. During the procedure, several interventional methods are available to reduce the degree of regurgitation, including balloons, snares, and valve-in-valve.”
Another key point for clinicians to remember is that newer TAVR systems are being designed to help limit PVL. They can be repositioned, for instance, and their smaller sheath size should lead to fewer vascular complications. This has led to “promising results” in studies that focus on these newer systems, the team noted.
The detailed analysis ended with a look ahead.
“Future studies should standardize the scaling methods of post-TAVR PVL and ensure a better classification of its severity,” the authors wrote. “Future TAVR devices should be designed to minimize the occurrence of PVL, and emerging interventional technologies, such as noninvasive debulking methods of the calcification of the aortic root, may contribute to lower PVL rates after TAVR.”
Read the full systematic review here.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.