Download PDF
Kardiologie up2date 2014; 10(01): 61-77
DOI: 10.1055/s-0034-1365304
Aortenerkrankungen
© Georg Thieme Verlag KG Stuttgart · New York

Residuelle paravalvuläre Prothesenleckage nach TAVI – prognostisch relevant?

Polykarpos C. Patsalis
,
Fadi Al-Rashid
,
Raimund Erbel
,
Philipp Kahlert
Further Information

Publication History

Publication Date:
10 April 2014 (online)

Also available at
    Permissions and Reprints All articles of this category

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 ∆PDAP – 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, ∆PDAP – 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 7 Kodali SK, Williams MR, Smith CR et al. Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement. NEJM 2012; 366: 1686-1695
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 22 Oliveros RA, Boucher CA, Groves BM et al. Myocardial supply-demand ratio in aortic regurgitation. Chest 1979; 76: 50-55
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 24 Hoffman JI, Buckberg GD. The myocardial supply-demand ratio: a critical review. Am J Cardiol 1978; 41: 327-333
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 29 Buellesfeld L, Grube E. A permanent solution for a temporary problem. J Am Coll Cardiol Intv 2012; 5: 578-581
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 37 Webb JG, Binder RK. Post-dilating transcatheter heart valves. J Am Coll Cardiol Intv 2012; 5: 513-514
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 39 Vavuranakis M, Vrachatis D, Stefanadis C. CoreValve aortic bioprosthesis: repositioning techniques. JACC CardiovascInterv 2010; 3: 565-566
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar