Mid-term Outcomes And Durability Of Transcatheter Aortic Valve Replacement At A Federal Facility
Rachel Yang1, Vimala Ponna1, Joshua Gustafson1, Kendrick Shunk1, Jeffrey Zimmet1, Liang Ge1, Elanie Tseng2.
1San Francisco Veteran's Administration Medical Center, San Francisco, CA, USA, 2San Francisco Veteran's Administration Medical Center, San Franciscooo, CA, USA.
Background- Transcatheter aortic valve replacement (TAVR) has become the predominant treatment for patients with severe aortic stenosis of any surgical risk. However, TAVR durability is unknown, impacting low-risk younger patients. Veterans Affairs Medical Centers (VAMC) are not required to submit TAVR outcomes to the Society of Thoracic Surgeons Transcatheter Valve Therapy registry, but instead report to VA databases for surgery and interventional cardiology. Therefore, limited mid-term TAVR is available from VAMC. Using recently standardized definitions of structural valve degeneration (SVD) and bioprosthetic valve failure (BVF), our objective was to evaluate short and mid-term outcomes of TAVR at a VA facility. Methods- As the 4th VAMC approved for TAVR, we retrospectively evaluated our first 335 TAVR patients from November 2013 to May 2020 for short and mid-term clinical outcomes. Standardized criteria of SVD and other endpoints were used from the European Association of Percutaneous Cardiovascular Interventions and Valve Academic Research Consortium-2 consensus statements.Results- 335 patients (age 78.0±8.5 years) underwent TAVR with 82 self-expanding, and 253 balloon-expandable devices implanted. Overall device success was 97.6%.Survival at 30 days was 98.8%, 1 year was 89.5%, 3 years was 72.1%, and 5 years was 58.8%. Short-term 30-day procedural outcomes included (n,%): permanent pacemaker (52, 15.5%), bleeding (19, 5.7%), cerebrovascular accident (9, 2.7%), vascular injury (14, 4.1%), cardiac tamponade (4, 1.1%), temporary hemodialysis (1, 0.2%), and acute kidney injury (8, 2.4%). Mid-term outcomes included (n,%): SVD (13, 3.9%), thromboembolism (15, 4.5%), bioprosthetic valve failure (4, 1.1%), and endocarditis (4, 1.1%).TAVR SVD was categorized by: moderate hemodynamic SVD (10, 3.0%), severe hemodynamic SVD (1, 0.2%), or morphological SVD with leaflet integrity abnormality (1, 0.2%). Patients with SVD consistently had mean transprosthetic gradients >20mmHg, with the exception of 1 patient who spontaneously resolved to normal gradients. One patient underwent aortic reintervention, and 1 patient underwent paravalvular leak repair. Conclusions- We demonstrated excellent short and mid-term TAVR outcomes at a VA facility. SVD was evident at a low but detectable rate in the first 6 years. Further follow-up and understanding of TAVR biomechanics will be essential for informing patient-specific risk of SVD over time, particularly for low-risk younger patients.
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