TAVR: Is There Trouble in Paradise?

By Rajesh Dave

I was the fortunate physician who had the privilege of performing the very first commercially approved Sapien valve procedure in the USA (2011).  Since then, we have seen great advancements in valve technology deployment techniques and variety of trials to reduce hospital stay to make TAVR the most cost-effective.  As we travel through this journey, we will continue to encounter new issues as expected with any new procedure.  A recent publication by Azeem Latib et al focuses on late coronary occlusion post TAVR.

In this publication, they evaluated 17,000 patients from 18 centers between 2005 & 2016 in a retrospective manner.  There was 0.22% incidence of delayed coronary obstruction.  Moreover, these phenomena noted to be higher amongst VIV procedure than native value TAVR (0.89% vs 0.18%, p<0.001).  It was also higher with Self Expanding Value vs. BE Valve (0.36% vs 0.11%, p< 0.01).  Either they presented in the first week or after 60 days with days 7 to 59 as the honeymoon period.

Approximately 1/3 of patients presented with cardiac arrest and just under 1/3 with STEMI.  The left coronary artery was by far the most common culprit 92.1%, although RCA was obstructed in 26.3% of patients.  PCI was the most common treatment, but success rate was higher with left coronary artery 80.8% than RCA 16.6%.  Overall, 50% patients with delayed obstruction died in the hospital.

Clearly this analysis raises important concerns about how we follow-up with these patients as well as patient selection and careful evaluation of aortic apparatus on CT &TEE.  It is hard to make any conclusion about association with valve type without a head-to-head randomized trial with long-term follow-up.

Since the inception of TAVR, C3 has focused its TAVR session on how to best select the patient and procedure for the best durable outcome.  Once again, this year we have renewed our commitment to this cause.  On June 20th in Orlando, experts in the field will gather to discuss this and many other important issues related to TAVR.  Furthermore, Dr. Henning Rud Andersen, the inventor of TAVR, will deliver a keynote address on June 18th2018 C3 is the meeting you should not miss!

Leave a Reply

Your email address will not be published. Required fields are marked *