Self-expanding transcatheter aortic valve infolding: Current evidence, diagnosis, and management.

Background: Prosthetic valve infolding is a rare but severe complication of transcatheter aortic valve implantation (TAVI) with self-expanding valves. However, currently available clinical data are limited and fragmented.
Objectives: This report aims to provide a comprehensive overview of this complication focusing on predisposing factors, clinical presentation, diagnostic findings, treatment and clinical outcomes.
Methods: A systematic review of the literature was performed to identify cases of infolding occurring during TAVI with self-expanding valves published until August 2020. These data were pooled with all the retrospectively identified infolding cases occurred at San Raffaele Scientific Institute between December 2014 and August 2020.
Results: A total of 34 cases were included. Among patients with available data, 38% received a first-generation CoreValve, and 62% a second-generation Evolut R (82%) or Evolut PRO (18%). Infolding occurred mostly with ≥29-mm valves (94%). Predisposing factors included resheathing of a second-generation valve (82%), heavy calcification of the native valve (65%), lack of predilatation (16%), Sievers type-1 bicuspid aortic valve (11%), and improper valve loading (5%). Infolding resulted in severe PVL causing hemodynamic instability (29%) or cardiac arrest (12%).
Postdilatation was the treatment strategy in 68%, while prosthesis replacement with a new device in 23% of cases. Device success rate was 82%. Death and stroke occurred in 3% and 12% of cases.
Conclusions: Prosthetic valve infolding is typically observed after resheathing of a large-size self-expanding TAVI. When infolding is timely diagnosed, prosthesis removal and replacement should be pursued. Further studies are required to precisely define predisposing factors to prevent this complication.

doi: 10.1002/ccd.29432.

背景：人工瓣膜折叠是经导管主动脉瓣植入术（TAVI）中，使用自扩张瓣膜时罕见但严重的并发症。然而，目前可用的临床数据有限且分散。目标：本报告旨在对该并发症进行全面概述，重点关注致病因素、临床表现、诊断发现、治疗和临床结果。方法：通过系统回顾文献，识别了截至2020年8月期间发表的TAVI中使用自扩张瓣膜发生的折叠病例。这些数据与2014年12月至2020年8月期间在圣拉法埃尔科学研究所回顾性识别的所有折叠病例进行了汇总。结果：共纳入34个病例。在可提供数据的患者中，38%接受了第一代CoreValve，62%接受了第二代Evolut R（82%）或Evolut PRO（18%）。折叠主要发生在≥29毫米的瓣膜中（94%）。致病因素包括第二代瓣膜的重新包装（82%）、原瓣膜严重钙化（65%）、缺乏预先扩张（16%）、Sievers型1型二尖瓣主动脉瓣（11%）和不适当的瓣膜加载（5%）。折叠导致严重的心脏瓣膜反流，引起血流动力学不稳定（29%）或心脏骤停（12%）。后扩张是治疗策略之一，在68%的病例中应用，而在23%的病例中，则采用新装置的瓣膜置换。装置成功率达到了82%。在3%的病例中发生了死亡，12%的病例中发生了中风。结论：人工瓣膜折叠通常发生在大尺寸自扩张TAVI的重新包装之后。当折叠得到及时诊断时，应进行瓣膜移除和更换。需要进一步的研究以精确地定义致病因素，以预防这种并发症。doi: 10.1002/ccd.29432。