Urgent implantation of a supplementary valve along with primary transcatheter aortic-valve replacement (TAVR) is associated with increased short-term morbidity and mortality, according to new findings. "Patients who require implantation of a supplementary TAV during their TAVR have worse outcome, in terms of more than twice the mortality rate at one month," said Dr. Uri Landes of of Tel-Aviv University in Israel. "This is because they may suffer more periprocedural complications such as coronary obstruction, strokes, annular rupture and bleeding," he told Reuters Health by email. Dr. Landes and colleagues analyzed registry data on more than 21,000 TAVR procedures carried out between 2014 and 2019. In all, 223 patients underwent two-valve (2V) TAVR. Incidence of 2V-TAVR fell from 2.9% in 2014 to 1.0% in 2018. After exclusions and propensity matching, outcome in 213 2V-TAVR patients was compared with that in 852 standard-TAVR patients. In the majority of cases (80%) the second valve was implanted because of incorrect positioning of the first valve, which caused residual aortic regurgitation. A review of the procedural records indicated various situations "that may have been preventable in a sizable proportion of cases," the researchers report in JAMA Cardiology, including poor visualization and pacing failure. Among other patient characteristics and procedural factors independently associated with 2V-TAVR were a bicuspid aortic valve, and use of an early-generation or self-expandable valve. The rate of device success was 70.4% in 2-TAVR versus 92.2% in TAVR (P<0.001). The corresponding hazard ratio for mortality at 30 days was 2.58 (P=0.04), but it was no longer significantly different at one and two years. Whether "complications occur due to the implantation of the second valve per se, or rather from the mal-implantation of the first valve or maybe from attempts to correct its position by certain other bailout maneuvers," is not yet known, continued Dr. Landes. "We should remember that surgical AVR may . . . be a good alternative option to urgent TAV-in-TAV, especially in low-surgical-risk patients currently undergoing TAVR," he said. Dr. Landes concluded that, "as the indication to implant the second valve was incorrect positioning of the first valve in the vast majority of the cases, we must minimize this risk, especially in patients at higher risk such as those with significant aortic regurgitation or bicuspid aortic valve or when using self-expandable devices or non-transfemoral access." —David Douglas Source
