TAVR for Aortic Regurgitation

Alternative approach

    Aortic valve disease has evolved considerably in the last two decades, mainly due to the advent of TAVR as a treatment for aortic stenosis. However, patients with concomitant aortic regurgitation were excluded from the first studies. After the interventionists’ greater expertise and confidence, cases of major double injury began to be addressed and, more recently, patients with isolated aortic regurgitation were treated with percutaneous treatment.

In early stages, first generation devices demonstrated a high complication rate in the treatment of this isolated pathology, due to low annular calcification. However, new devices, especially those that could be repositioned, proved to be more suitable for the treatment of aortic regurgitation.

One of the complications that presented the worst prognostic impact was paraprosthetic regurgitation, or leak. Individuals with residual leak greater than or equal to moderate, had worse survival than those who showed adequate patency.

The incidence of the need for a second prosthesis implant was also higher than in the treatment of aortic stenosis, but the fact of using repositionable and even “retractable” prostheses made the number of complications to be reduced, because in case of leak or inadequate expansion, the prosthesis was repositioned or rotated, with good results at the end of the procedure.

In this context, the risk of embolization or dislocation of the implanted prosthesis exists, therefore the need for an intra-procedure valve-in-valve for better anchoring of the device. A detailed analysis of the tomography before the procedure and the choice of prosthesis with high radial force or discrete oversizing, can be crucial to avoid this complication.

As it is an intervention modality still in the initial learning curve, the time for the procedure in general is longer, as well as the contrast spent. Fluoroscopy is inadequate, given the low annular calcification, requiring transesophageal echocardiography for proper assessment, making a minimalist approach impossible. Dilated annulus and aortic aneurysms, common situations in isolated aortic regurgitation, are complicating and even prohibiting the percutaneous procedure.

Therefore, due to an off-label procedure and because it still considers greater safety, how much to use, or use of TAVR for isolated arterial regurgitation is not contraindicated, but should be reserved for cases of high medical risk in patients with various comorbidities, after adequate discussion on the Heart Team and analysis of multimodality imaging exams.

Suggested literature:

1 – Yoon SH, Schmidt T, Bleiziffer S, et al. Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. J Am Coll Cardiol. 2017; 70 (22): 2752‐2763.

 

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