Commentary: Leaflet perforation after transcatheter aortic valve implantation in calcified roots: When perfect can be the enemy of good?

Central MessageTranscatheter approach is often preferred for aortic valve replacement in presence of a calcified aortic root; the extent of such calcifications may affect the durability of transcatheter prosthesis.See Article page 92. Transcatheter approach is often preferred for aortic valve replacement in presence of a calcified aortic root; the extent of such calcifications may affect the durability of transcatheter prosthesis. See Article page 92. The presence of advanced atherosclerotic disease in the ascending aorta has represented one of the main indications for transcatheter aortic valve replacement (TAVR) as an alternative to conventional surgical aortic valve replacement in high-risk patients. In the present issue of the Journal, Liesman and Fukuhara1Liesman D.R. Fukuhara S. Leaflet perforation/tear late after transcatheter aortic valve implantation.J Thorac Cardiovasc Surg Tech. 2020; 3: 92-94Google Scholar present 2 cases of leaflet perforation and perivalvular leaks following the implantation of a self-expandable transcatheter bioprosthesis in calcified roots; based on such findings, the authors raise a concern whether leaflet perforation after TAVR in patients with severely calcified aortic root could represent an under-recognized complication. In particular, both patients in this series had previously undergone chest radiation therapy. Radiation therapy to the mediastinum can be associated with significant valvular abnormalities, manifesting as progressive valve thickening and calcification, resulting in valve restriction and dysfunction that presents as stenosis and/or regurgitation. Such degenerative changes have been shown to extend also to the aorto-mitral curtain and to be independently associated with mortality in patients undergoing cardiac surgery.2Veeragandham R.S. Goldin M.D. Surgical management of radiation-induced heart disease.Ann Thorac Surg. 1998; 65: 1014-1019Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar,3Desai M.Y. Wu M. Masri A. Popovic Z.B. Agarwal S. Smedira N.G. et al.Increased aorto-mitral curtain thickness independently predicts mortality in patients with radiation-associated cardiac disease undergoing cardiac surgery.Ann Thorac Surg. 2014; 97: 1348-1355Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar While most reports focus on surgical treatment of native valve disease after radiation, there are no reports regarding the use of TAVR post-radiotherapy. The underlying mechanism of postimplant leaflet damage in both self-expandable and balloon-expandable prosthesis is multifactorial. Potential causes include leaflet damage during crimping or implantation, manufacturing defects, and inadequate closing pressure due to abnormal flow hemodynamics.4Holmes Jr., D.R. Mack M.J. Kaul S. Agnihotri A. Alexander K.P. Bailey S.R. et al.2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement.J Am Coll Cardiol. 2012; 59: 1200Crossref PubMed Scopus (618) Google Scholar, 5Khoffi F. Heim F. Mechanical degradation of biological heart valve tissue induced by low diameter crimping: an early assessment.J Mech Behav Biomed Mater. 2015; 44: 71-75Crossref PubMed Scopus (23) Google Scholar, 6Convelbo C. El Hafci H. Petite H. Zegdi R. Traumatic leaflet injury: comparison of porcine leaflet self-expandable and bovine leaflet balloon-expandable prostheses.Eur J Cardiothorac Surg. 2018; 53: 1062-1067Crossref PubMed Scopus (10) Google Scholar Furthermore, the expanding possibility of crimping TAVR devices into lower-profile delivery catheters could potentially lead to a greater chance of collagen fibers in the tissue leaflets being exposed to fragmentation.7Kiefer P. Gruenwald F. Kempfert J. Aupperle H. Seeburger J. Mohr F.W. et al.Crimping may affect the durability of transcatheter valves: an experimental analysis.Ann Thorac Surg. 2011; 92: 155-160Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar,8Alavi 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 Furthermore, it is now widely accepted that an asymmetric dilatation of the transcatheter valve can lead to increase stress and accelerated prosthetic degeneration, either in balloon-expandable or self-expandable valves9Dasi L.P. Hatoum H. Kheradvar A. Zareian R. Alavi S.H. Sun W. et al.On the mechanics of transcatheter aortic valve replacement.Ann Biomed Eng. 2017; 45: 310-331Crossref PubMed Scopus (58) Google Scholar: the presence of extensive calcifications at the level of the aortic valve and the root can represent a controversial element in terms of ideal suitability for a TAVR procedure, since either the lack of the excess of calcium can significantly impact procedural success and therefore also durability.10Qian Z. Lancellotti P. Vannan M.A. Aortic root calcium burden and post-transcatheter aortic valve implantation paravalvular leak: can't live without it, can't live with it.Eur Heart J Cardiovasc Imaging. 2017; 18: 654-656Crossref PubMed Scopus (3) Google Scholar Clearly, it could be argued that the presence of a previous history of radiation to the mediastinum can increase the likelihood of more severe changes in the native valve but could also potentially affect the implanted transcatheter prosthesis, unlike the surgical setting, which allows for routine valve and annular debridement. In conclusion, the chronic changes following chest radiation could potentially lead to a hostile environment, more so for a transcatheter approach than a surgical one, as in the current experience by the Liesman and Fukuhara,1Liesman D.R. Fukuhara S. Leaflet perforation/tear late after transcatheter aortic valve implantation.J Thorac Cardiovasc Surg Tech. 2020; 3: 92-94Google Scholar and eventually leading to a surgical procedure anyhow. This is another elegant example about how carefully TAVR use should be expanded in a fast-expanding pool of 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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