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Redo Transcatheter Aortic Valve Replacement Safe, Effective
MONDAY, Sept. 11, 2023 (HealthDay News) — Redo transcatheter aortic valve replacement (TAVR) procedures are as safe and effective as native TAVR in select patients, according to a study published online Aug. 31 in The Lancet.
Raj R. Makkar, M.D., from Cedars-Sinai Medical Center in Los Angeles, and colleagues assessed the safety and efficacy of redo TAVR in a national registry. The analysis included all consecutive patients in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry (Nov. 9, 2011, to Dec. 30, 2022) who underwent TAVR with balloon-expandable valves in either failed transcatheter heart valves (redo TAVR; 1,320 patients) or native aortic valves (native TAVR; 349,271 patients).
The researchers found that the rates of procedural complications of redo TAVR were low (coronary compression or obstruction: 0.3 percent; intraprocedural death: 0.6 percent; conversion to open heart surgery: 0.5 percent) and overall similar to native TAVR. For death at 30 days (4.7 versus 4.0 percent) or one year (17.5 versus 19.0 percent) and stroke at 30 days (2.0 versus 1.9 percent) or one year (3.2 versus 3.5 percent), there were no significant differences between redo-TAVR and native-TAVR populations, respectively. At one year, redo TAVR reduced aortic valve gradients, although they were higher in the redo-TAVR group versus the native-TAVR group (15 versus 12 mm Hg). Rates of moderate or severe aortic regurgitation did not differ significantly between the redo-TAVR and native-TAVR groups at one year (1.8 versus 3.3 percent). Timing of redo TAVR (before or after one year of index TAVR) and index transcatheter valve type (balloon-expandable or non-balloon-expandable) did not significantly affect death or stroke after redo TAVR.
"Redo-TAVR with balloon-expandable valves might be a reasonable treatment for failed TAVR in selected patients," the authors write.
Edwards Lifesciences funded the study.
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Heart Valve Disease: Treatment Considerations
Medically reviewed by Anthony Pearson, MD, FACC
Heart valves help your blood flow in the heart and to your body. Heart valve disease—or valvular heart disease—can occur due to age, certain heart conditions, or issues present from birth. Not everyone with heart valve disease has symptoms, but those with symptoms should see a healthcare provider to determine the underlying cause and seek treatment.
This article discusses surgical and nonsurgical heart valve disease treatment. It also covers types of heart valve disease, related symptoms, risks of leaving it untreated, and treatment options.
Normal Heart Valve FunctionThe heart has four chambers: the left and right atria and the left and right ventricles. The heart also has four valves with flaps that ensure blood moves as it should in the heart and around your body. Each of the valves has a specific responsibility, as follows:
Aortic valve: Lets blood flow from the left ventricle to the aorta, the main artery carrying blood away from the heart to the rest of the body
Mitral valve: Allows blood flow from the left atrium to the left ventricle
Pulmonary valve: Lets blood flow from the right ventricle to the pulmonary artery
Tricuspid valve: Directs blood flow from the right atrium to the right ventricle
If the valves don't open or close as they should, it is harder for the heart to work correctly.
Types of Heart Valve DiseaseIf you are diagnosed with heart valve disease, it will be categorized as one of the following types:
Regurgitation occurs when a valve's flaps don't close as tightly as they should, allowing blood to move backward—prolapse, or when the valve's flaps flop, commonly causes regurgitation.
Stenosis is when the valve flaps become narrowed due to calcification or thickening. This can block the heart valve from fully opening, preventing adequate blood from passing through it. Some people develop regurgitation and stenosis.
Atresia is an improperly formed heart valve with no opening for blood to pass through.
Heart valve disease and heart failure are not the same thing. Heart valve disease refers to a problem with one of the heart valves. Heart failure is when the heart does not pump blood through the body as it usually would. Though, sometimes, heart valve disease can cause heart failure.
Risks of Untreated Heart Valve DiseaseNot all heart valve problems require immediate treatment. In some cases, a healthcare provider may monitor the progression of the heart valve condition before moving toward treatment.
Other times, treatment is immediately necessary and can help avoid more serious, sometimes fatal complications, including:
Atrial fibrillation: An irregular heart rate or rhythm
Heart failure: When the heart does not pump blood through the body as it normally would
Pulmonary hypertension: A type of high blood pressure that affects the arteries in the heart and lungs
Stroke: Loss of blood flow to the brain
Sudden cardiac arrest (heart attack): Loss of blood flow to the heart
It's possible to have a heart valve problem throughout your life and not know it as it has no symptoms. In most cases, heart valve disease progresses slowly, eventually leading to symptoms.
You may feel more tired than usual with heart valve disease or wonder why you're out of breath with physical activity when it didn't cause any problems before. Symptoms of heart valve disease include the following:
Arrhythmia, or inconsistency with your heart's rate or rhythm
Chest pain
Dizziness
Fainting
Fatigue
Low or high blood pressure
Swelling in the abdomen, ankles, feet, or neck veins
Shortness of breath
Medication can sometimes help control symptoms associated with heart valve disease, though it may not cure it. Depending on the cause of your heart valve disease, a provider may prescribe you blood pressure medication such as diuretics or vasodilators to support your heart's function.
Qualifying for Heart Valve Disease SurgeryYou may need surgery when one or more of your heart valves is not functioning properly and is negatively impacting your health. To decide if heart valve disease surgery is the best option for you, your healthcare provider will consider:
Your age
The type of heart valve disease that you have
The structure of your heart
Other medical conditions that could limit your ability to have heart valve surgery
Before surgery, you may have to have other tests to give your provider more information about your valve disease. Make sure to ask in advance about any alternatives to having surgery so that you know all of your options.
Ask in advance about any costs associated with the surgery and financial support available within your health system.
Types of Heart Valve Disease SurgeriesIf your heart valve issue requires surgery, your provider will determine if you need a repair or a replacement, which involves the following:
Heart valve replacement: During valve replacement, a provider may use a biological valve—made from animal or human tissue—or a mechanical valve.
Heart valve repair: During heart valve repair, the heart surgeon may mend torn leaflets in the valve, separate fused valve leaflets, or reshape valve parts.
One of the latest forms of heart valve replacement called transcatheter aortic valve replacement (TAVR), does not involve traditional surgical incision. Procedures using catheters inserted into the veins or arteries are now available to replace the aortic valve with severe aortic stenosis and to repair the mitral valve with severe mitral regurgitation.
The type of surgery used will depend on the exact heart valve problem; each comes with risks.
Some people undergo open heart surgery involving a larger chest incision to access the heart. During the surgery, you are connected to a heart-lung bypass machine that will do the work of your heart during the procedure.
Other heart valve surgeries are less invasive, involving more minor cuts to complete the surgery. There is less pain and a quicker recovery associated with minimally invasive surgeries.
Monitoring and Following-Up With Heart Valve DiseaseIf you have heart valve surgery, it could take between four and eight weeks to recover. Follow any instructions your healthcare provider or surgeon gives you.
Your provider will likely ask you to participate in cardiac rehabilitation to restore your cardiovascular function. Make sure to attend these sessions. Ask for support from friends or family members to complete tasks you may not be able to do, including taking care of children and pets or doing household chores.
If your provider does not recommend surgery for you but wants to monitor the progress of your heart valve disease, keep any scheduled appointments.
SummaryHeart valve disease can occur with age, from a heart condition, or due to genetics. The most common types of heart valve disease are regurgitation, stenosis, and atresia. Medications for heart valve disease can help control the symptoms but won't cure the disease.
A heart surgeon may perform a heart valve repair or replacement for more severe cases. Untreated heart valve disease may lead to severe problems because the heart has to work harder. These include atrial fibrillation, heart failure, and sudden cardiac arrest or death.
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Redo TAVI With Balloon-Expandable Valves Shows Promise In Treating Failed Transcatheter Aortic Valves
Registry data has revealed that redo transcatheter aortic valve implantation (TAVI) using balloon-expandable valves effectively treats stenosis or regurgitation in failed transcatheter aortic valves among older patients. This approach demonstrates minimal complications, comparable to those seen in native TAVI procedures. The study published in Lancet by Makkar RR and colleagues brings valuable insights into the management of failed transcatheter heart valves.
Key findings from the study:
● Patient Demographics: The study included 350,591 consecutive patients who underwent TAVI with balloon-expandable valves. Among the 1,320 patients who underwent redo TAVI, the average age was 78 years, with 42.3% being female. The mean predicted surgical risk of 30-day mortality was 8.1%.
● Safety and Complications: Analysis of 1,320 propensity-matched pairs showed that patients undergoing redo TAVI experienced low rates of complications, including coronary compression or obstruction (0.3%), intraprocedural death (0.6%), and conversion to open-heart surgery (0.5%). These rates were similar to those observed in native-valve TAVI procedures.
● Outcomes: There were no significant differences between the redo and native TAVI groups in terms of death at 30 days (4.7% vs. 4.0%) or at one year (17.5% vs. 19.0%) and stroke at 30 days (2.0% vs. 1.9%) or one year (3.2% vs. 3.5%). Aortic valve gradients were higher in the redo TAVI group compared to the native TAVI group at one year (15 vs. 12 mm Hg).
● Valve Durability: The study noted improved valve durability over time. However, a proportion of patients (18.4%) in the redo TAVI group were left with residual gradients of at least 20 mm Hg at discharge.
● Patient Selection: Redo TAVI was considered safe and effective in this study, but it was emphasized that the patient population selected for the procedure might represent those who were at high risk for surgery or had anatomically favourable conditions for redo TAVI.
While the study provides valuable insights into the safety and efficacy of redo TAVI with balloon-expandable valves, it is noted that the patient population studied may not reflect all scenarios, particularly those involving late failure of transcatheter valves. Further research is needed to address long-term outcomes and identify the best strategies for managing patients with failed transcatheter valves.
Experts believe that as transcatheter valve technology advances, the lessons learned from redo TAVI procedures will contribute to improved patient care, especially in younger and lower-risk populations. The study highlights the importance of thorough patient selection and
careful monitoring during redo TAVI procedures. Future research may focus on optimizing valve combinations and planning strategies for the best patient outcomes.
The study, published in The Lancet, suggests that redo TAVI with balloon-expandable transcatheter valves could be a reasonable option for selected patients who are deemed appropriate for redo TAVI by their heart teams. However, it also underscores the need for continued research in this evolving field of cardiac interventions.
Reference:
Makkar RR, Kapadia S, Chakravarty T, et al. Outcomes of repeat transcatheter aortic valve replacement with balloon-expandable valves: a registry study. Lancet. 2023
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