CORRESPONDENCE: LETTER TO THE EDITOR
Percutaneous Aortic Valve Replacement With the CoreValve Prosthesis
Rachid Zegdi, MD, PhD*,
Ghassan Sleilaty, MD,
Antoine Lafont, MD, PhD and
Jean-Noël Fabiani, MD
* Hôpital Européen Georges Pompidou, Service de Chirurgie Cardiovasculaire, 20, rue Leblanc, 75908 Paris, France (Email: rzegdi{at}hotmail.com).
We read with interest the recent article of Grube et al. (1) dealing with percutaneous aortic valve implantation. They reported the experience from 3 centers using the second and third generations of the CoreValve prosthesis (CoreValve Inc., Irvine, California) in 86 consecutive patients. The acute device success was high (88%), and the 30-day mortality was low (12%) in these surgically high-risk patients with mean pre-procedural logistic Euroscores of 21.7%. Hemodynamically, the mean transvalvular gradient dropped from 43.7 to 9.0 mm Hg with a concomitant improvement in the New York Heart Association functional class.
We would like to comment on these results and also ask for some clarifications regarding their data.
When reporting data after aortic valve implantation, one would expect to have information regarding the aortic prosthetic valve area and the rate of prosthesis–patient mismatch. One cannot be satisfied by the transvalvular gradient alone, knowing that a high proportion of patients with left ventricular systolic dysfunction were included in the study. These data are important because they will allow comparison among percutaneous valves themselves and with the surgically implanted prosthetic valves, thus improving the information given to patients.
In the same way, we regret that the post-procedural incidence and severity of perivalvular leakage were not detailed as was the case for the pre-procedural intravalvular regurgitation.
We were surprised that exclusion criteria did not include bicuspid aortic valves. In our experience, stent deployment may be impaired in bicuspid aortic stenosis (2), a condition with an incidence that can reach 50% of the surgically operated patients (3). Furthermore, in the series of Cribier et al. (4), all of the native aortic valves were tricuspid.
We were also surprised by the high rate of procedural valve dilations after valve implantations (28% of the 76 valve implantations) to achieve good stent expansions. We wonder if this high rate of subsequent dilation reflects undiagnosed bicuspid aortic stenosis.
Information regarding major bleeding is lacking (a rate of 24% has been reported in a previous study [5]). Likewise, the peripheral vascular complications and their management were not reported. One would like to know whether their incidence was dependent on the type (open [with a cut down] or closed) of vascular access during the procedure.
Atrioventricular block is a classic complication after surgical aortic valve replacement. It seems that it is also the case after percutaneous valve implantation. Data regarding this complication in the series should also be provided.
Finally, there is actually only one available size of CoreValve, with a 21-mm bioprosthesis implanted within the stent frame (2). As researchers, we do not understand how proper sizing could be achieved in patients with aortic annulus diameters ranging from 20 to 27 mm. Mismatch will inevitably lead to leaflet distortion or restriction (Rachid Zegdi, personal communication, December 2006), with a potential negative impact in the long term.
Although many points of the study require further clarification, we would like to thank the authors for their important work and contribution to this important new field of interventional therapy.
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Footnotes
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Please note: Dr. Zegdi is a stock owner in a company (Coremove) developing a new percutaneous valve.
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References
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1. Grube E, Schuler G, Buellesfeld L, et al. Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the second- and current third-generation self-expanding CoreValve prosthesis J Am Coll Cardiol 2007;50:69-76.[Abstract/Free Full Text]2. Zegdi R, Khabbaz Z, Ciobotaru V, Noghin M, Deloche A, Fabiani JN. Calcific bicuspid aortic stenosis: a questionable indication for endovascular valve implantation? Ann Thorac Surg 2007In press. 3. Roberts WC, Ko JM. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or without associated aortic regurgitation Circulation 2005;111:920-925.[Abstract/Free Full Text] 4. Cribier A, Eltchaninoff H, Tron C, et al. Treatment of calcific aortic stenosis with the percutaneous heart valveMid-term follow-up from the initial feasibility studies: the French experience. J Am Coll Cardiol 2006;47:1214-1223.[Abstract/Free Full Text] 5. Grube E, Laborde JC, Gerkens U, et al. Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve diseaseThe Siegburg first-in-man study. Circulation 2006;114:1616-1624.[Abstract/Free Full Text]
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