Hemodynamics and Mid-Term Clinical Outcomes Following Valve-in-Valve TAVR With Balloon-Expandable Valves

Area of Science:

• Cardiology
• Medical Devices
• Echocardiography

Background:

• Lower discharge echocardiographic mean gradients (<10 mm Hg) after transcatheter aortic valve replacement (TAVR) with balloon-expandable valves correlate with lower ejection fraction and increased 5-year mortality.
• The relationship between mean gradients (MGs) and patient-prosthesis mismatch (PPM) following transcatheter aortic valve-in-valve replacement (TAV-in-V) and clinical outcomes requires further investigation.

Purpose of the Study:

• To investigate the association between echocardiographic mean gradients (MGs) and patient-prosthesis mismatch (PPM) after TAV-in-V procedures.
• To determine the impact of MGs on 5-year mortality in patients undergoing TAV-in-V.

Main Methods:

• Analysis of 13,054 patients who underwent TAV-in-V with a balloon-expandable valve from July 2015 to December 2023, using the STS/ACC TAVT Registry.
• Utilized adjusted Cox models with regression splines to examine the relationship between MG and 5-year mortality.
• Employed Kaplan-Meier estimates and adjusted hazard ratios to compare mortality rates across different gradient cutoffs and PPM severities.

Main Results:

• A nonlinear relationship was observed between discharge MG and 5-year mortality.
• Lower MGs (<10 mm Hg) were associated with higher 5-year mortality (HR, 1.15; P=0.024) and lower ejection fraction (50.4±13.9%) compared to higher MGs (≥10 mm Hg).
• Severe PPM and MGs ≥20 mm Hg were not significantly associated with worse 5-year outcomes compared to less severe PPM or lower MGs (≤20 mm Hg).

Conclusions:

• Discharge MGs <10 mm Hg after TAV-in-V are linked to reduced ejection fraction and increased 5-year mortality in a nonlinear manner.
• Integrating ejection fraction, PPM, and MG data is crucial for optimizing valve selection and patient management.