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Brain & Heart TAVR in low gradient aortic stenosis

higher 30-day mortality risk compared to patients without 6.5. Paravalvular leak (PVL)
a stroke. Brain imaging studies utilizing diffusion- PVL is a relatively common complication of TAVR.
40
weighted MRI have indicated that up to 84% of patients Although the calcified valves are required for the
41
develop new lesions after TAVR. The impact of cLFLGAS successful anchoring of the TAVR valve, calcification
on stroke outcomes after TAVR has been compared with might lead to partial sealing of the valve, resulting in
that of HGAS in multiple observational cohort studies and regurgitation around the valve. Trace-to-mild amounts of
prospective registries. No difference in stroke incidence PVL have been documented in up to 70% of patients. 48-51
was observed between cLFLGAS or pLFLGAS and HG Moderate-to-severe PVL has reported in up to 24% of
TAVR. 38
cases, depending on the type of valve used. However, with
Efforts have been made to mitigate the stroke risk the use of newer devices with increased skirt length and
through antithrombotic therapy. However, there is limited enhanced operator experience, PVL incidence has declined
evidence for the efficacy of antiplatelet or anticoagulant to <2%. In patients with cLFLGAS and reduced EF,
52
therapy currently. The 2020 ACC/AHA valvular heart regurgitation is more poorly tolerated, thus increasing the
42
disease guidelines advocate a class 2b recommendation for need for approaches to reduce PVL. To mitigate the risk
3
dual antiplatelet therapy or vitamin K antagonist therapy of developing post-procedural PVL, pre-TAVR planning
for 3 – 6 months after TAVR in patients with low bleeding is crucial to ensure adequate valve sizing, determine
risk, as well as a class 2a recommendation for lifelong the amount and location of annular calcium, estimate
aspirin administration in all patients who underwent the valve type, and ensure that valve implantation is not
TAVR. 11 too high or low. Options for PVL closure include post-
35
balloon dilation, implantation of a second valve, and use
6.4. Conduction disturbances of a vascular plug device. Data regarding PVL closure in
34
The bundle of His courses within the infero-anterior cLFLGAS TAVR are limited to case reports, and additional
portion of the membranous septum, and the left bundle research is necessary to elucidate the indications, risks, and
branch runs near the base of the commissure between ideal procedures for PVL closure in this population. 53
43
the non-coronary and right coronary cusps. Mechanical
manipulation of the aortic root may induce local 6.6. Acute kidney injury (AKI)
inflammation, edema, or ischemia. The incidences of AKI during the TAVR procedure is caused by the arterial
43
high-grade AV block and new-onset LBBB range from 4% contrast volume used embolization of debris into the renal
to 65%, and they are more commonly noted with the use vasculature, and states of hypoperfusion during rapid
of self-expandable valves rather than balloon-expandable pacing. Data from the STS/TVT registry found that
54
valves (CoreValve 27% [9% – 65%] vs. SAPIEN (11% [4% 10.7% of patients developed post-procedural AKI, with
– 18%]). 44,45 LBBB in patients with cLFLGAS can induce 9.5% in stage 1, 0.1% in stage 2, and 1.1% in stage 3. The
detrimental effects due to mechanical dyssynchrony, association with mortality became stronger with increasing
possibly offsetting the benefit achieved through TAVR’s AKI severity (2.7-fold in stage 1, 10.4-fold in stage 2, and
afterload reduction. The rate of pacemaker installation 7-fold in stage 3). 55
3
after TAVR ranges from 2.3% to 36.1%, with higher
rates observed with the use of self-expandable valves 6.7. Long-term complications
(SAPIEN 3 [4% – 24%] vs. Evolute R [14.7% – 26.7%]). 46 Bioprosthetic valve dysfunction (BVD) can be classified
Current observational studies demonstrate that there is into non-structural and structural complications. Non-
no difference between cLFLGAS and HG TAVR in terms structural complications include PVL (as detailed above)
of the need for pacemaker implantation or new-onset and patient–prosthesis mismatch (PPM). The incidence
LBBB. Prevention of conduction disturbances mainly of PPM is 23.9%, and there is mixed evidence about
38
relies on effective preprocedural planning to ensure whether PPM is linked to increased mortality. 56,57 Patients
appropriate implant depth and commissural alignment as with cLFLGAS have increased rates of PPM and severe
well as identify those who are at high risk for developing PPM (defined as indexed effective orifice area <0.65
conduction disturbances. A recent study indicated a cm /m ). Abbas et al. examined patients enrolled in the
2
2
45
negative predictive value of 98.7% if a patient does not PARTNER 2a and PARTNER registry data and discovered
develop Wenckebach following right atrial pacing before that severe PPM post-TAVR in patients with cLFLGAS
valve deployment. If a pacemaker is necessary, it is is independently associated with cardiac death and
47
important to consider chronic resynchronization therapy rehospitalization following TAVR (odds ratio, 1.85; 95%
for patients with cLFLGAS and reduced EF. 3 confidence interval [CI], 1.06 – 3.23; p = 0.0308). 58

Volume 3 Issue 1 (2025) 9 doi: 10.36922/bh.4017