Transcatheter Valve Replacement in Adults With Congenital Heart Disease-The Mayo Clinic Experience
Alexander C Egbe1, Allison K Cabalka2, Nathaniel W Taggart2
1Department of Cardiovascular Medicine (A.C.E., M.F.E., C.S.R.), Mayo Clinic Rochester, MN.
Insights
Transcatheter valve replacement in adults with congenital heart disease shows clinical improvement but faces challenges with prosthetic valve longevity. Further strategies are needed to enhance long-term outcomes and prosthesis durability.
Area of Science:
- Cardiology
- Interventional Cardiology
- Congenital Heart Disease
Background:
- Adults with congenital heart disease (ACHD) often require interventions for valve disease.
- Transcatheter valve replacement (TVR) offers a less invasive option for these complex patients.
Purpose of the Study:
- To describe the outcomes of transcatheter valve replacement in adults with congenital heart disease.
- To evaluate the temporal trends and long-term efficacy of TVR in ACHD.
Main Methods:
- Retrospective analysis of 341 ACHD patients undergoing TVR from 2010-2024.
- Study divided into early, mid, and late eras to assess temporal changes.
- Primary outcome: valve reintervention; secondary outcomes: mortality, prosthetic valve gradient, and clinical indices.
Main Results:
- TVR procedures increased over time.
- 10-year incidence of valve reintervention was 35% and all-cause mortality was 13%.
- Significant increase in prosthetic valve gradient observed within 10 years, indicating potential long-term limitations.
Conclusions:
- TVR in ACHD is associated with initial clinical improvement.
- Prosthetic valve gradient increases significantly over time, raising concerns about long-term durability.
- Strategies to improve prosthetic valve longevity are crucial for better outcomes in ACHD patients.
Background:
The current study aims to describe outcomes after transcatheter valve replacement in adults with congenital heart disease.
Methods:
Retrospective study of adults with congenital heart disease who underwent transcatheter valve replacement and had a 1-year follow-up postintervention at Mayo Clinic (2010-2024). The study period was divided into early (2010-2014), mid (2015-2019), and late (2020-2024) eras. The primary outcome was valve reintervention. The secondary outcomes were all-cause mortality and temporal change in prosthetic valve gradient and clinical indices of disease severity.
Results:
Overall, 341 patients (age 38±17 years; 175 [51%] men) received 346 prostheses (pulmonary [N=236, 68%], tricuspid [N=75, 22%], aortic [N=22, 8%], and mitral [N=7, 2%]). The prostheses were Sapien (N=181, 52%), Melody (N=142, 41%), and Harmony prostheses (N=23, 7%). The number of transcatheter valve implantations increased from the early era (N=75), mid era (N=109), to the late era (N=162). The 10-year incidence of valve reintervention was 35%, and was similar between Sapien versus Melody prosthesis (41% versus 33%; P=0.11). The 10-year incidence of all-cause mortality was 13%. There was a temporal increase in prosthetic valve Doppler mean gradient (baseline versus 10 years) for pulmonary (12±5 versus 28±11 mmHg; P<0.001), tricuspid (3±1 versus 8±3 mmHg; P<0.001), and aortic prosthesis (13±5 versus 26±12 mmHg; P<0.001). There was a temporal increase in predicted peak oxygen consumption (absolute ∆, 9% [95% CI, 4-13]; P=0.006) and a decrease in NT-proBNP (N-terminal pro-B-type natriuretic peptide) level (absolute ∆, -138 pg/mL [95% CI, -209 to -64]; P<0.001) at 1-year postintervention.
Conclusions:
There has been a temporal increase in the number of transcatheter valve implantations over time. Transcatheter valve replacement was associated with clinical improvement across multiple domains. However, there was a significant increase in prosthetic valve gradient within 10 years of follow-up, suggesting limited prosthesis longevity. There is a need for strategies to improve prosthetic valve longevity, which in turn may improve outcomes in this population.
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