Commentary: Leaflet perforation after transcatheter aortic valve replacement: An unsuspected complication with underestimated outcomes

Central MessageLeaflet perforation after transcatheter aortic valve implantation is a rare complication that may alter valve durability due to transcatheter valve leaflet vulnerability.See Article page 92. Leaflet perforation after transcatheter aortic valve implantation is a rare complication that may alter valve durability due to transcatheter valve leaflet vulnerability. See Article page 92. The indications for transcatheter aortic valve replacement (TAVR) have recently been widened to low-surgical risk patients.1Mack M.J. Leon M.B. Thourani V.H. Makkar R. Kodali S.K. Russo M. et al.PARTNER 3 InvestigatorsTranscatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380: 1695-1705Crossref PubMed Scopus (2388) Google Scholar As surgical risk decreases, so does the average age of the patients. One major consideration remains: TAVR prosthesis durability, which has been poorly investigated thus far. Several authors have suggested that different mechanisms, all involving some extent of leaflet damage, including cusp rupture, leaflet thrombosis, and accelerated calcification, could have major consequences on valve durability and therefore on patient outcomes after TAVR.2Alavi S.H. Groves E.M. Kheradvar A. The effects of transcatheter valve crimping on pericardial leaflets.Ann Thorac Surg. 2014; 97: 1260-1266Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar,3Park H. Wai Sang S.L. Merhi W.M. Extremely early structural failure of a self-expanding transcatheter aortic valve secondary to leaflet dehiscence.J Thorac Cardiovasc Surg Tech. March 19, 2020; ([Epub ahead of print])Google Scholar These lesions appear to be responsible for aortic regurgitation and the need for surgical explant.4Fukuhara S. Brescia A.A. Shiomi S. Rosati C.M. Yang B. Kim K.M. et al.Surgical explantation of transcatheter aortic bioprostheses: results and clinical implications.J Thorac Cardiovasc Surg. January 12, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar However, these lesions remain underdiagnosed. In this issue of the Journal, Liesman and Fukuhara5Liesman D.R. Fukuhara S. Leaflet perforation or tear late after transcatheter aortic valve implantation.J Thorac Cardiovasc Surg Tech. 2020; 3: 92-94Google Scholar report 2 cases of leaflet perforation with a need for surgical explant. These cases share several common aspects: first, both patients had a history of chest radiation therapy with severe root calcification; second, both cases received a TAVR procedure with a self-expandable valve after a primary sternotomy; and third, surgical explant because of aortic regurgitation was required in both cases after a short period following the TAVR procedure: 3 and 5.8 years. Similar macroscopic findings were also noted: neo-endothelialization of the TAVR prosthesis nitinol frame into the aortic wall, with a perforation/tear located on the right coronary cusp. Liesman and Fukuhara5Liesman D.R. Fukuhara S. Leaflet perforation or tear late after transcatheter aortic valve implantation.J Thorac Cardiovasc Surg Tech. 2020; 3: 92-94Google Scholar unmask a major unknown of TAVR prostheses: valve durability/longevity. The 2 cases occurred in the early- to mid-term follow-up post-TAVR, which suggests that leaflet fragility could have a negative impact on valve durability. Hypothetic risk factors for leaflet perforation were additional postdeployment balloon dilatation, as well as crimping of the prosthesis, which has also been reported by others.2Alavi S.H. Groves E.M. Kheradvar A. The effects of transcatheter valve crimping on pericardial leaflets.Ann Thorac Surg. 2014; 97: 1260-1266Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar In addition, they suggested that valve durability could be further affected by implanting the prosthesis into an undecalcified native aortic valve and aortic root. This article is important because the authors effectively shed some light into a potential mechanical failure of TAVR due to the leaflet injury. The newer generation of TAVR bioprostheses has leaflets that are generally thinner to accommodate the smaller caliber of the delivery sheaths, which may translate into a potentially increased fragility of the leaflets. Further mechanical stress may be due to the crimping process, recapturing, and postdeployment balloon dilatation, and may render the leaflets vulnerable to perforation and subsequent thrombosis, although these theories remain hypothetical. Further studies are needed to assess these issues. Liesmann and Fukuhara5Liesman D.R. Fukuhara S. Leaflet perforation or tear late after transcatheter aortic valve implantation.J Thorac Cardiovasc Surg Tech. 2020; 3: 92-94Google Scholar have exposed a novel but potentially underdiagnosed complication of TAVR prosthetic leaflet perforation. The durability of TAVR prostheses should be considered in our decisional algorithm when assessing the optimal approach to aortic stenosis, especially in younger patients. Leaflet perforation or tear late after transcatheter aortic valve implantationJTCVS TechniquesVol. 3PreviewA 70-year-old woman had a medical history notable for breast cancer with chest irradiation after 23-mm Freestyle (Medtronic Inc, Minneapolis, Minn) inclusion root replacement in 2008 for radiation-associated aortic stenosis, followed by valve-in-valve transcatheter aortic valve replacement (TAVR) in 2014 with a 23-mm CoreValve (Medtronic Inc) because of structural valve degeneration. Completion aortography showed a mild paravalvular leak for which postimplant balloon valvuloplasty using a 20-mm noncompliant balloon was performed. Full-Text PDF Open Access

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